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DISEASES 


OF    THE 


Stomach  and  Intestines 


BY 


BOARDMAN   REED,    M.  D. 

MEMBER    OF   THE   AMERICAN    IVIEDICAL    ASSOCIATION,    AMERICAN   CLIMATOLOGICAL 
ASSOCIATION,     AMERICAN    ACADEMY     OF     MEDICINE,     FOREIGN     MEMBER    OF    THE 
FRENCH    SOCIETE    D'ELECTROTHERAPIE  ;     CONSULTING    GASTRO-ENTEROLOGIST 
TO   THE   POTTENGER    SANATORIUM,    MONROVIA,    CAL. ;     CONSULTING    PHYSI- 
CIAN   TO    THE    COREY    SANATORIUM     AND     HOSPITAL,     ALHAMBRA,     CAL.; 
LATE     PROFESSOR     OF     DISEASES     OF    THE     GASTRO-INTESTINAL    TRACT, 
HYGIENE    AND     CLIMATOLOGY     IN    THE    DEPARTMENT    OF   MEDICINE 
OF     TEMPLE     UNIVERSITY  ;     LATE     PHYSICIAN-IN-CHIEF   TO   THE 
SAMARITAN     HOSPITAL;     LATE     PHYSICIAN    TO    THE    AMERI- 
CAN  ONCOLOGIC   HOSPITAL,    PHILADELPHIA,  ETC. 


ILL  USTRA  TED 


THIRD    EDITION 

THOROUGHLY   REVISED  AND  LARGELY   REWRITTEN 


NEW    YORK 

E.    B.    TREAT   &   COMPANY 

241-243  West  230  Street 
1911 


Copyright,  1904,  1907,  1911 

BY 

E.   B.   TREAT    &    COMPANY 


THE  QUINN  &    BOOEN  CO.  PRESS 


PREFACE  TO  THIRD  EDITION. 

In  the  nearly  seven  years  since  this  work  first  appeared,  the 
number  of  important  papers  published  on  the  special  group  of 
subjects  which  it  covers,  has  been  enormous.  The  task  of  go- 
ing through  them  all  in  order  to  bring  the  present  edition  up 
to  date  has  been  correspondingly  great.  Professor  Stanley  P. 
Black,  of  the  University  of  California,  has  kindly  consented  to 
revise  the  chapters  on  the  examination  of  the  urine  and  feces, 
and  his  eminence  as  a  pathologist  is  an  assurance  that  it  has 
been  well  done.  To  Dr.  W.  P.  Millspaugh,  lecturer  on  gastro- 
intestinal diseases  in  the  same  institution,  has  been  delegated 
the  duty  of  reviewing  the  countless  books  and  papers  which 
have  appeared  in  various  languages  concerning  ulcer,  carci- 
noma, etc.,  and  his  collaboration  with  me  in  revising  the  parts 
of  this  book  relating  thereto  has  been  a  most  valued  service. 
So  great  and  life-saving  have  been  the  advances  in  the  Surgery 
of  the  Stomach  and  Intestines,  and  in  the  closely  allied  subject 
of  Intestinal  Obstruction,  that  the  revision  of  the  chapters  on 
these  has  been  intrusted  to  an  experienced  and  scholarly 
surgeon,  Dr.  James  P.  McReynolds,  lately  of  Philadelphia, 
who  has  almost  entirely  rewritten  a  large  part  of  them.  Dr. 
F.  M.  Pottenger,  the  distinguished  expert  in  tuberculosis,  has 
generously  placed  at  my  disposal  the  large  amount  of  interest- 
ing clinical  material  in  his  sanatorium  for  tuberculous  cases 
at  Monrovia,  Cal. ;  and  Dr.  J.  E.  Pottenger,  the  pathologist 
of  that  institution,  has  kindly  aided  in  collating  for  me  the 
statistics  of  the  same.  Dr.  F.  E.  Corey,  of  the  Alhambra 
Sanatorium  and  Hospital,  has  rendered  assistance  in  studying 
cases  which  have  been  under  our  joint  care  there.  To  all  these 
gentlemen  I  return  my  grateful  thanks. 

Important  changes  with  many  large  additions  have  been 
made  in  most  of  the  chapters,  and  a  number  of  them  have 


PREFACE    TO    THIRD    EDITION 

been  largely,  some  of  them  entirely,  rewritten.  A  new  chapter 
has  been  added  on  Arteriosclerosis,  in  which  its  relations  with 
gastro-intestinal  affections  have  been  discussed  in  the  light  of 
our  present  knowledge,  including  reports  of  some  original  ob- 
sewations  on  blood-pressure  by  the  author. 

BoARDMAN  Reed. 

Alhambra  (Los  Angeles),  Cal., 
December,  1910. 


PREFACE  TO  SECOND  EDITION. 

So  short  a  time  has  elapsed  since  the  appearance  of  the  first 
edition  of  this  work  that  extensive  changes  in  it  have  not  been 
found  necessary.  Note  has  been  taken,  however,  of  the  more 
important  advances  and  improvements  in  the  special  field  which 
it  aims  to  cover.  New  material  has  been  added  to  eighteen  of 
the  lectures  and  alterations  have  been  made  in  the  text  where 
required. 

In  several  particulars  prominence  was  given  in  the  first 
edition  to  views  which  were  then  in  advance  of  current  medical 
opinion;  and  some  of  these  provoked  adverse  criticism  in  cer- 
tain quarters.  They  included  ( i )  the  recognition  of  eye-strain 
as  a  cause  of  gastro-intestinal  symptoms;  (2)  the  advocacy  of 
a  very  large  dependence  upon  hygiene  and  diet  as  well  as  upon 
electrical  and  other  mechanical  methods  of  treatment  in  pref- 
erence to  routine  drug-giving;  (3)  advising  the  avoidance  in 
so  far  as  practicable  of  instrumentation  in  the  stomach  and 
suggestions  as  to  possible  methods  for  determining  approxi- 
mately the  motor  and  secretory  functions  of  that  viscus  with- 
out even  the  use  of  the  tube,  when  exactness  is  not  necessary; 
and  (4)  recommending  a  cautious  use  of  tuberculin  in  the 
diagnosis  and  treatment  of  tuberculosis  of  the  digestive  organs. 
During  the  last  two  years  the  trend  of  medical  thought  has  been 
in  these  directions  more  and  more,  and  especially  with  regard 
to  the  employment  of  tuberculin,  there  is  now  a  preponderance 
of  opinion  in  favor  of  it  as  shown  by  communications  from 
many  leading  clinicians  in  both  Europe  and  America. 

To  Dr.  Harold  Brunn  of  San  Francisco  I  am  indebted  for  a 
revision  of  the  lecture  on  the  Surgery  of  the  Stomach  and  In- 
testines and  for  making  the  additions  to  it  necessary  to  bring 
it  into  fuller  accord  with  the  present  status  of  that  subject. 

BoARDMAN  Reed. 

Los  Angeles,  Cal.,  November,  1906. 


PREFACE 

The  majority  of  physicians  now  in  practice  have  had  no 
opportunity  of  learning  the  newer  methods  available  in  the 
diagnosis  and  treatment  of  diseases  of  the  digestive  system; 
hence  books  describing  them  are  necessary.  These  methods 
are  better  than  the  old  ones  because  far  more  accurate  and 
efhcient.  They  are  indispensable  to  the  successful  management 
of  many  of  the  prevalent  gastro-intestinal  affections. 

Yet  books  upon  this  subject  have  been  multiplying  during  the 
last  ten  years,  and  it  may  well  be  asked,  Why  add  to  the  num- 
ber? The  question  would  be  justifiable,  since  the  subject  has 
been  treated  most  ably  and  exhaustively  by  several  American 
writers,  to  say  nothing  of  the  works  by  foreign  authors — 
Ewald,  Boas,  Riegel,  et  al.,  which  have  been  translated  into 
English.  I  could  not  hope  to  rival  them  in  completeness  and 
erudition,  nor  in  the  profundity  with  which  they  have  consid- 
ered some  of  the  many  as  yet  unsolved  pathologic  problems  in 
this  field. 

There  does  not  at  present,  however,  exist  in  the  English 
language  any  work  which,  in  a  single  volume,  treats  of  the 
whole  subject  of  diseases  of  the  stomach  and  intestines  from 
the  standpoint  of  our  present  knowledge. 

Not  only  general  practitioners,  but  also  specialists  in  other 
lines  who  find  it  necessary  to  keep  informed  in  a  general  way 
with  regard  to  digestion  and  nutrition,  have  discussed  with  me 
what  they  desire  to  have  in  such  a  book.    They  want  a  not  too 


PREFACE 

bulky  volume,  which  should  contain  brief,  but  easily  intelligible, 
descriptions  of  the  simplest  reliable  tests  for  the  necessary  ob- 
jects of  study  in  the  gastric  contents  and  feces,  as  well  as  the 
most  practicable,  and  especially  the  least  disturbing,  methods 
of  determining  the  position,  size,  and  motility  of  the  stomach, 
colon,  etc. — /.  e.,  demonstrating  dilatation  or  displacements 
of  any  of  the  abdominal  viscera,  including  abnormal  mobility 
of  the  kidneys — together  with  a  brief  statement  of  so  much  of 
the  pathology  and  aetiology  of  the  different  gastro-intestinal 
affections  as  is  certainly  known;  besides  a  full  account  of  the 
symptoms  and  diagnosis,  and  especially  an  ample  consideration 
of  the  treatment.  To  meet  these  requirements  the  single- 
volume  work  must  necessarily  omit  much  of  interest,  such  as 
historic  observations,  speculative  discussions  as  to  mooted 
points  in  aetiology  and  pathology,  and  the  bibliography  of  this 
special  subject,  which  has  now  grown  to  vast  proportions. 

In  this  volume  of  lectures  the  attempt  has  been  made  to 
furnish  such  a  book  as  is  above  outlined — a  plain  and  unpreten- 
tious, but  practically  complete,  clinical  guide  to  the  diagnosis 
and  treatment  of  the  diseases  in  question.  I  am  fully  con- 
scious of  its  many  imperfections,  for  which  the  indulgence  of 
readers  is  craved.  It  embodies,  however,  the  results  of  much 
personal  experience  during  a  long  and  busy  practice,  and  an 
earnest  effort  honestly  to  record  and  interpret  this  experience. 
Furthermore,  while  duly  conservative  as  to  advising  the 
abandonment  of  old  and  well-tried  remedies,  I  have  in  these 
lectures  given  such  credit  as  seemed  due  to  the  most  recent 
innovations  in  the  way  of  therapeutic  resources  for  the  diseases 
under  consideration,  especially  the  applications  of  electricity  in 
all  its  forms,  including  the  electrostatic  currents  and  x-rays; 
also  the  violet  rays,  radium,  etc.,  as  well  as  mechanical  vibra- 


PREFACE 

tion,  manual  therapy,  hydrotherapy,  exercise  (active  and 
passive),  and  all  the  approved  hygienic  measures,  particularly 
an  unusually  full  consideration  of  the  exceedingly  important 
subject  of  diet. 

The  lectures  are  based  in  part  upon  those  delivered  to  my 
classes  in  the  Department  of  Medicine  of  .Temple  College, 
Philadelphia,  and  in  part  upon  the  "  Talks  to  General  Practi- 
tioners "  contributed  by  me  to  the  International  Medical 
Magazine  during  the  five  years  that  it  was  under  my  editorial 
management.  All  of  these  have  been  carefully  revised,  and 
many  of  them  almost  entirely  rewritten.  A  still  larger  number 
of  the  lectures  have  been  prepared  expressly  for  the  present 
work,  including  a  special  one  entitled,  A  Symptomatic 
Guide  to  Diagnosis.  This  unique  feature,  it  is  hoped,  will 
prove  useful  to  both  students  and  practitioners.  I  am  under 
obligations  to  my  associates.  Dr.  W.  E.  Rahte  and  Dr.  George 
O.  Jarvis,  for  valuable  assistance  in  preparing  this  and  several 
of  the  other  lectures. 

Thanks  are  due  also  to  my  colleague,  Prof.  W.  Wayne 
Babcock,  for  permission  to  incorporate  in  the  lecture  on  Dis- 
placements of  the  Colon  his  particularly  interesting  illustrated 
paper  upon  that  subject,  and  to  my  colleague.  Prof.  A.  Robin, 
for  contributing  toward  several  of  these  lectures,  including 
especially  those  upon  Examination  of  the  Feces  and  upon 
Bacteria  and  Animal  Parasites  in  the  Gastro-intestinal 
Tract,  which  were  mainly  written  by  him.  I  am  also  indebted 
to  Dr.  G.  Morton  Illman,  my  clinical  assistant  at  the  Samaritan 
Hospital,  for  aid  in  getting  up  the  section  on  The  Blood  in 
Gastro-intestinal  Diseases.  The  clear  and  succinct  lecture  on 
Diseases  of  the  Rectum  and  Anus  has  been  very  kindly  con- 
tributed   by    that    well-known    proctologist.    Dr.    Collier    F. 


PREFACE 

Martin,    instructor   in    Rectal    Diseases   at   the    Philadelphia 
Polyclinic. 

To  my  friend  and  former  teacher,  Prof.  C.  A.  Ewald  of 
Berlin,  and  to  Prof.  Sidney  Martin  of  London  I  am  under 
particular  obligations  for  permission  to  reproduce  a  number 
of  choice  illustrations  from  works  written  by  them,  also  to 
several  other  medical  friends  and  to  various  makers  of  surgical 
instruments  for  the  use  of  electrotypes  illustrating  special  ap- 
paratus or  other  objects  of  interest.  Specific  credit  is  given 
under  each  illustration. 

Messrs.  E.  B.  Treat  &  Co.  of  New  York,  the  publishers  of 
this  volume,  are  entitled  to  praise  for  the  very  creditable  dress 
in  which  it  appears  and  for  the  courteous  assistance  which  they 
have  rendered  me  at  every  stage  of  the  work. 

BoARDMAN  Reed. 


CONTENTS 

PART  I 

ANATOMIC,  PHYSIOLOGIC,  CHEMIC,  AND 
DIAGNOSTIC  DATA 

Lecture  I.     Anatomy  of  the    Digestive  Tract 

PAGE 

The  Pharynx — The  Esophagus — Abdominal  Cavity — The 
Stomach — The  Gastric  Glands — Conclusions — The  Blood- 
Vessels  of  the  Stomach — The  Veins  and  Lymphatics — 
The  Intestinal  Canal — The  Duodenum — The  Cecum — 
The  Colon — The  Sigmoid  Flexure — The  Rectum — Struc- 
ture of  the  Stomach  and  Intestines — The  Liver — The 
Pancreas  .........       29 

Lecture  II.     The    Nerve    Supply    of    the    Digestive 

Organs  and  the  Relations  of  the  Spine  to  the 

Vaso-Motor  Nerves 

Secretory  Nerves — The  Vaso-Motor  Nerves  and  the  Spine — 
Course  and  Direction  of  the  Spinal  Nerves — Points  of 
Emergence  from  the  Spine  of  Special  Vaso-Motor  Nerves       47 

Lecture  III.     The   Physiology   of   Digestion^  Absorp- 
tion^ AND  Defecation 

Salivary  Digestion — Gastric  Digestion — Intestinal  Digestion — 

Absorption — Defecation  .         .         .         .         .         .       54 

PART  II 
METHODS  OF  EXAMINATION 

Lecture  IV.     The  Interrogation  of  the  Patient 

Importance  of  a  Full  History — Systematic  Questioning — How 
to  Detect  Dietetic  Sins — Pain  or  Discomfort — Bowel 
Movements — The  Genito-Urinary  System         ...        65 


CONTENTS 

Lecture  V.     The  Physical  Examination  of  the 
,  Patient 

PAGE 

General  Considerations — Inspection — Palpation — Ausculatation 
and  Percussion — Instruments  for  Determining  the  Size 
and  Position  of  the  Viscera       .         .         .         .         .         -73 

Lecture  VI.     The    Author's    Method    of    Outlining 
THE  Stomach  and  Determining  the  State  of  its 
Motor  Function — Other  Methods  of  Exam- 
ining THE  Viscera 

A  Combination  of  External  Methods — Experiments  with  Dif- 
ferent Methods  of  Determining  the  Size  and  Position  of 
the  Stomach — A  New  Pleximeter — The  Determination 
of  the  Gastric  Motor  Power — Inflation  of  the  Stomach 
and  Colon — Summary  of  Author's  Method — Radiographs 
of  the  Viscera — The  Capacity  and  Motor  Power  of  the 
Stomach — Tests  of  the  Capacity  of  the  Stomach — The 
Salol  Test  of  Gastric  Motility — Other  Methods  of  Test- 
ing the  Motility  of  the  Stomach 90 

Lecture  VII.     The    Examination    of    the    Secretory 

Function  of  the  Stomach — Instruments  Used 

for  the  Extraction  of  the  Stomach 

Contents 

How  to  Introduce  the  Tube  into  the  Stomach  with  the  Least 
Possible  Embarrassment  of  the  Patient — Preparation  of 
the  Patient — Introducing  the  Tube — Training  of  Irritable 
Throats — The  Kuttner  Aspirator    .         .         .         .         .108 

Lecture  VIII.     Test    Meals    and    Preparations    for 
Testing  the  Stomach  Contents 

Concerning  Test  Meals — The  Ewald  Breakfast — The  Test 
Dinner — The  Lactic-Acid  Free  Meal — No  Single  Test 
Meal  Conclusive — An  Objectionable  Method  of  Getting 
the  Stomach  Contents — The  Macroscopic  Examination 
of  the  Stomach  Contents — Bile,  Blood,  Feces,  or  Pus  in 
the  Stomach  Contents — The  Fluidity  of  the  Stomach 
Contents — Filtering  the  Stomach  Contents       .         .         .117 


CONTENTS 

Lecture    IX.      Qualitative    Tests    of    the    Stomach 

Contents 

PAGE 

Tests  for  Lactic  Acid — Tests  for  the  Other  Organic  Acids — 
Tests  of  the  Salivary  Digestion — Tests  for  the  Pepsin 
and  Rennet  Ferments — Tests  for  Albumin,  Propeptone, 
and  Peptones — An  External  Method  of  Testing  for  Gas- 
tric Acidity — Significance  of  Increased  Tympany  after 
Administering  Sodium  Bicarbonate  ....      126 

Lecture  X.     Quantitative    Estimations    and    Micro- 
scopic Examinations  of  the  Stomach  Contents 

The  More  Important  Quantitative  Tests  of  the  Stomach  Con- 
tents— Quantitative  Test  for  Lactic  Acid — Quantitative 
Test  for  Fatty  Acids — Microscopic  Examination  of  Stom- 
ach   Contents  .         .         .         .         .         .         .         .135 

Lecture  XL     The    Urine    in    G astro-Intestinal  Dis- 
ease— Uranalysis  an  Aid  in  Estimating  the 
Secretion  of  HCl 

Uranalysis  Indispensable  in  Gastro-Intestinal  Affections — Re- 
lation between  Urinary  Acidity  and  HCl  Secretion — 
Importance  of  Estimating  the  Chlorides — The  Determi- 
nation   of    the    Chlorides         ......      143 

Lecture  XII.     The  Urine,  Continued:  Significance  of 
Indicanuria  and  Tests  for  It 

Indicanuria,  High  Acidity,  etc. — A  Quick  Test  for  Indican — 
Approximate  Quantitative  Test  for  Indican — Test  for 
the  Total  Amount  of  Solids     .         .         .         .         .         .148 

Lecture  XIII.     The  Urine,  Concluded:  Tests  for  Uric 
Acid,  Urea,  and  the  Acidities — Laboratory  Outfit 

Tests  for  Uric  Acid — Folin-Hopkins  Method  of  Determining 
the  Amount  of  Uric  Acid — Urea — Test  for  the  Total 
Acidity — Freund  and  Topfer's  Test  for  the  Urinary  Acid- 
ities— Biliary  Pigments  and  Acids — Acetone  and  Dia- 
cetic  Acid — Lieben's  Iodoform  Test  for  Acetone — Lab- 
oratory Outfit .         •     153 


CONTENTS 

Lecture  XIV.     The  Examination  of  Feces;  and  the 
Blood  in  Gastro-Intestinal  Diseases 

PAGE 

The  Feces  in  Health — The  Microscopic  Examination — The 
Color — Various  Foreign  Substances  to  be  Looked  for — 
Microscopic  Examination — The  Blood  in  Gastro-Intestinal 
Diseases — To  Obtain  a  Specimen  of  Blood — The  Tech- 
nique of  the  Examination — Blood  Counts — To  Estimate 
the  Hemoglobin — Lead  Colic  Diagnosed  from  Other  Pains 
by  the  Blood 162 

Lecture  XV.     A  Symptomatic  Guide  to  Diagnosis 

Anorexia,  or  Impaired  Appetite — Breath,  Fetor  or  Foul  Taste 
in  Mouth — Bulimia,  or  Excessive  Appetite — Constipation 
— Debilit}^ — Defecation,  painful — Discolorations  of  the 
Skin,  Jaundice  or  Bronzing — Diarrhea — Depression 
Mental  or  Nervous — Emaciation — Eructations — Excita- 
bility, Undue — Flatulency,  Gastric  or  Intestinal — Head- 
ache— Hemorrhage,  or  Loss  of  Blood  or  Altered  Blood,  by 
Mouth  or  Rectum — Insomnia,  or  Impaired  Sleep — Irrita- 
bility of  Temper — Nausea,  or  Vomiting — Oppression  or 
Weight  in  Stomach — Pain  Referred  to  the  Right  H^^po- 
chondriac  Region  or  Lower  Edge  of  Liver — Pain  Referred 
to  the  Region  of  the  Stomach — Pallor  of  Skin — Ptj^alism, 
or  Salivation — Regurgitation,  or  Rumination — Succession 
of  Splashing  Sounds  in  the  Abdomen — Tenderness  on 
Pressure  over  the  Epigastrium — Tenesmus — Tongue 
Coated  or  Furred — T3'mpany,  Abdominal — Vertigo         .      179 

PART  III 
METHODS  OF  TREATMENT 

Lecture   XVI.     Prophylaxis:    Personal    Hygiene    and 
Food  Requirements 

Personal  Hygiene — The  Hygiene  of  Eating  and  Drinking — 
Definition  of  Food — Alcohol  and  Food  Accessories — 
Classification  of  Foods — Proportions  of  Different  Foods 
in  the  Normal  Diet  According  to'  Various  Authorities — 
Some  Recent  Experiments  Concerning  Food  Requirements     191 


CONTENTS 

Lecture  XVII.     General  Considerations  Concerning 
Diet  and  Dietotherapy 

PAGE 

Relative  Importance  of  Dietetics — Resting  the  Stomach — 
Wegele's  Estimate  of  Dietetics — Diseased  Stomachs  Need 
Rest — Summary  of  Precautions — Dietetic  Faults  the 
Most  Frequent  Causes  of  Gastro-Intestinal  Disease — The 
Arrangement  of  Meals  with  Relation  to  Rest  and  Exer- 
cise— Regularity  in  Times  of  Eating  Essential         .         .     204 

Lecture  XVIII.     The  Diet  in  Irritative  and  Atonic 
Conditions 

Classification  of  Diseases  with  Regard  to  Dietetic  Treatment — 
The  Diet  in  Irritative  Conditions — The  Diet  in  Atonic 
Conditions — The  Diet  in  Diarrhea  and  Constipation — 
Proper  Cooking  and  Thorough  Mastication — Dangers  in 
Overrestriction  of  the  Diet — Diet  in  the  Uratic  Diathesis     216 

Lecture  XIX.    Sugar,  Spices,  etc.,  in  Gastro-Intestinal 

Cases 

The  Most  Difficult  Point  in  a  Difficult  Subject — -An  Experi- 
ment Worth  Trying — Why  the  Sweets  often  Disagree 
after  a  Dinner — The  Spices,  Condiments,  and  Beverages — 
The  Spices,  etc..  Drugs,  not  Foods — The  Alcoholic 
Liquors — Coffee  and  Tea — ^Water,  Milk,  etc.         .         .     226 

Lecture  XX.     The  Author^s  and  Other  Progressive 
Series  of  Diets 

Classes  of  Cases  for  which  Specified  Diets  are  Indicated — 
Diet  Directions  of  Leube  and  Penzoldt — Leube's  Diet 
Scheme — Penzoldt's  Diet  Tables  for  the  Gradual  Train- 
ing of  the  Digestive  Capacity         .....     234 

Lecture  XXI.     Feeding  by  Other  Routes  than  the 

Mouth 

The  Technique  of  Rectal  Alimentation — Boas'  Formula  for  a 

Nutrient  Enema — The  Injection  of  Food  Subcutaneously     248 


CONTENTS 

Lecture  XXII.     Methods   of   Treatment   in   Gastro- 
intestinal Diseases 

PAGE 

Therapeutic  Methods — Overdosing  and  Overdoing  in  Thera- 
peutics .........     253 

Lecture  XXIII.     The  Remedial  Value  of  Active  Exer- 
cises Including  Outdoor  Games,  Gym- 

NASTICSj  ETC. 

Exercise    Indispensable — Various    Kinds  of    Exercise — Special 

Forms  of  Gymnastics  Recommended         .         .         .         .     259 

Lecture  XXIV.     Passive  Exercises,  Including  Massage 
— The  Rest  Treatment 

Massage  and  Swedish  Movements — HCl  Increased  by  Mas- 
sage— Cases  of  Hyperchlorhydria  Produced  by  Massage — 
Cases  of  Hyperchlorhydria  Aggravated  by  Massage — In- 
dications for  Massage  of  Abdomen — The  Rest  Treatment     268 

Lecture  XXV.     Electricity,    Galvanic,    Faradic,    and 

Static — High-Frequency  and  Polyphase 

Currents 

Electricit)^ — The  Continuous  Current,  or  Galvanism — The  In- 
duced Current,  or  Faradic  Electricity — Static  Electricity — 
High-Frequency  Currents — Polyphase  Currents         .         .     278 

Lecture  XXVI.     Various  Forms  of  Electric  and  Hy- 
dro-Electric Currents  Applied  Directly  within 
THE  Bowel 

Hydro-Electric  Applications  within  the  Bowel — Measures  to 
Combat  Possible  Collapse  from  Sudden  Emptying  of  the 
Bowel — The  Hydro-Electric  Method  in  Muco-Membra- 
nous  Enteritis  ........     286 

Lecture  XXVII.     Other  Direct   Methods  of  Treat-  - 
iNG  the  Intestines 

Carbon  Dioxide  in  Diseases  of  the  Rectum  and  Colon — Turck's 
Colonic  Treatment — Turck's  Method  of  Doing  Lavage 
of  the  Colon — Flushing  of  the  Colon — Technique  of  Ad- 
ministering Oil  Enemas  ..*...     296 


CONTENTS 

Lecture  XXVIII.     Vibration^  Manual  Therapy,  and 
Other  Mechanical  Forms  of  Treatment 

PAGE 

The  Advantages  Claimed  for  Mechanical  Vibration — Manual 
Therapy — Counter-irritants — Heat  and  Cold — Mydriatic 
Procedures — Phototherapy — Similarity  of  the  Effects  of 
the   Different   Mechanical   Methods         ....     304 

Lecture  XXIX.     Intragastric  Methods  of  Treatment 

— Lavage,  Intragastric  Spray,  etc. 

When  and  How  to  Wash  out  the  Stomach — The  Intragastric 

Douche    and    Spray         .  .  .  .  .  .         .312 

Lecture   XXX.     Intragastric    Methods,    Continued — 
Intr.4gastric  Electricity 

As  Simple  as  Lavage — Intragastric  Electrodes — The  Author's 
Modification  of  the  Einhorn  Electrode — Effect  of  Intra- 
gastric Electricity  upon  Secretion — Action  of  Faradic  Cur- 
rents on  Secretion — Reports  of  Two  Illustrative  Cases — 
The  Technique  of  Applying  Electricity  Intragastrically     .     321 

Lecture  XXXI.     The  Medicinal  Therapy  of  Diseases 
OF  THE  Stomach  and  Intestines 

The  Administration  of  Acids — The  Place  of  Hydrochloric 
Acid  in  the  Treatment  of  Diseases  of  the  Stomach — Re- 
ports of  Cases — Later  Experience  with  HCl     .         .         .331 

Lecture  XXXII.     Digestants,  Alkalies,  and  Natural 
Spring  Waters 

The  Digestants — A  Series  of  Experiments — Confirmatory 
Clinical  Evidence — Useless  Pepsin  Compounds — Pancre- 
atic Preparations — Alkalies  in  Gastro-Intestinal  Disease — 
The  Alkaline  Mineral  Waters — The  Effect  of  Alkalies 
before  and   after   Meals — The   Sodium   Chloride  Waters     345 

Lecture  XXXIII.     Tonics,  Stimulants,  and  Sedatives 

The  Nerve  Tonics — Alcohol  Rarely  Necessary — The  Relief  of 
Pain  and  Insomnia  Produced  by  Disease  of  the  Stomach 


CONTENTS 


PAGE 


or  Bowels — Iron  and  Its  Principal  Preparations — The 
Ferruginous  Mineral  Waters — The  Bismuth  Preparations 
and  Cerium  Oxalate — The  Bland  Oils     ....     354 

Lecture  XXXIV,  Antiseptics,  Astringents,  and  Laxa- 
^        TivES — Minute  Doses  of  Certain  Drugs 

Antiseptics — Astringents — Laxatives  and  Purgatives — The 
Usefulness  of  Certain  Drugs  in  Minute  Doses — Cuprum 
Arsenite  .........     361 

PART  IV 

THE  GASTRO-INTESTINAL  CLINIC 

Lecture  XXXV.     Introductory — The     Classification 

OF  Diseases 
Diseases  of  the  Stomach  and  Intestines  not  always  Separable     .     371 

Lecture  XXXVI.     Gastric  Atony,  or  Myasthenia  Gas- 
TRicA.     (Motor  Insufficiency;  Mechanical 
Insufficiency) 
Relative  Importance  of  Atony,  Dilatation,  etc. — Various  De- 
gress   of   Atony — ^^tiology — Symptomatology — Diagnosis 
— Simple  Tests  of  Gastric  Motility — Treatment     .  .     378 

Lecture  XXXVII.  Dilatation  of  the  Stomach.  (Di- 
latAtio  Ventriculi;  Gastrectasis) 

Acute  Gastrectasis — The  Etiology  of  Chronic  Gastrectasis — 
Symptomatology — Complications  and  Consequences  of 
Gastric  Dilatation — Tetany     .         .         .         .         .         .386 

Lecture  XXXVIII.     The  Diagnosis  of  Dilatation  of 

THE    Stomach 
Differential    Diagnosis  .......     396 

Lecture  XXXIX.     Treatment  of  Dilatation  of  the 

Stomach 

i'rognosis — Treatment — Dilatation  from  Pyloric  Spasm — In- 
tragastric Electricity — ^Treatment  of  Atonic  Dilatation — 
The  Treatment  of  Gastric  Tetany  ....     405 


CONTENTS 

Lecture  XL.     Splanchnoptosis^    or    Downward     Dis 

placements  of  the  abdominal  organs  generally 

(Nephroptosis^  Gastroptosis^  and  Enter- 

oPTOSis)  ;  Movable  Kidney 

PAGE 

Movable  Kidney — Nephroptosis — ^^tiology — Symptomatology 
— Diagnosis  of  ^Movable  Kidney — Treatment  of  Mova- 
ble Kidnc}' — Strapping  the  Abdomen  for  Displacements 
— Other    Remedial    Measures  .         .         .         .         .415 

Lecture  XLL  Splanchnoptosis,  Continued:  Dis- 
placements AND  Distortions  of  the  Stomach 

Gastroptosis  —  xEtiology  —  Sj'mptomatology  —  Diagnosis  — 
Prognosis — Treatment — Volvulus  of  the  Stomach — Hour- 
Glass  Contraction — Abnormally  Small  Stomachs — Con- 
genital Anomalies  of  the  Stomach — Congenital  Stenosis 
of    the    Pylorus       ,..,....     429 

Lecture    XLIL      Splanchnoptosis,     Continued:     Dis- 
placements OF  THE  Colon 

Coloptosis — The  Symptoms  of  Coloptosis — Diagnosis — Treat- 
ment— Importance  of  Correcting  Displacements        .        .     440 

Lecture  XLIIL     Splanchnoptosis,     Continued:     Dis- 
placements OF  THE  Liver,  Spleen,  and  Small 
Intestines — General  Considerations 
Concerning  Displacements,  etc. 

Hepatoptosis — Movable  Spleen — Displacements  of  the  Small 
Intestine — Symptoms — Treatment — Some  Statistics  of 
Displacements,  etc. — Abdominal  Displacements  as  Causes 
of  Pelvic  Disease     ........     456 

Lecture  XLIV.     Displacements,   etc.,  of  the  Abdom- 
inal Viscera,  Concluded,  with  Reports  of 
Illustrative  Cases 

Reports  of  Cases  of  Displacements  of  the  Stomach,  Colon,  etc. 
— Pronounced  Gastroptosis — Dilated  Stomach,  Movable 
Kidney,  etc. — Comparison  of  the  Results  from  Surgical  and 
Mechanical  Treatment — Conclusions       ....     464 


contents 
Lecture  XLV.     Acute  and  Subacute  Gastritis 


PAGE 


Patholog}'  of  the  Gastric  Inflammations — Simple  Acute  Gas- 
tritis— Symptoms — Diagnosis — The  Treatment  of  Acute 
Gastritis — Medicinal    Remedies — Subacute   Gastritis         .     471 

Lecture  XLVL     Acute  and  Subacute  Gastritis,  Con- 
cluded: Sympathetic,  Toxic,  Phlegmonous,  and 
Infectious  and  Parasitic  Gastritis 

Sympathetic  Gastritis — Toxic  Gastritis — Patholog}^ — Symp- 
toms— Diagnosis — The  Treatment  of  Toxic  Gastritis — 
Phlegmonous,  or  Purulent  Gastritis — Patholog)' — Sj'mp- 
toms — Diagnosis — Treatment — Infectious  and  Parasitic 
Gastritis  .  .  .  .  .  .  .  .  .     479 

Lecture       XLVII.     Chronic       Asthenic       Gastritis; 
(Chronic  Gastric  Catarrh) 

Different  Forms  of  Chronic  Gastritis — Chronic  Hypertrophic 
Gastritis — The  Patholog)'  of  Chronic  Gastritis  in  Gen- 
eral— Symptomatology — Diagnosis — Prognosis  .         .     485 

Lecture    XLVIII.     The    Treatment   of    Chronic   As- 
thenic Gastritis  (Chronic  Gastric  Catarrh) 

The  Treatment,  Dietetic  and  Hygienic — Beverages — Mechani- 
cal Forms  of  Treatment — Lavage — ^Washing  the  Stomach 
Downward — diodes  of  Stimulating  the  Gastric  Muscles 
— Medicinal    Treatment  ......     496 

Lecture    XLIX.      Chronic    Sthenic    Gastritis    (Acid 
Gastric  Catarrh) 

JEtlolog)' — Patholog}^ — Symptomatology- — The  Diagnosis  from 

Ulcer — Microscopic  Examination     .....     504 

Lecture    L.      The    Treatment    of    Chronic     Sthenic 

Gastritis  (Acid  Gastric  Catarrh),  and  of 

Hydrochloric  Acid  Excess 

The  Treatment  of  Acid  Gastritis — The  Diet — Intragastric 
Electricity — Other  Methods  of  Applying  Electricitj^ — 
The  Medicinal  Treatment — The  Treatment  of  Hj^per- 
chlorhydria      .         .         ,         .         ,         .         .         .         -513 


CONTENTS 

Lecture    LI.     Excessive    Secretion    of    Gastric    Juice 
(Hyperchlorhydria,  or  Hyperchylia^  Gas- 

TROXYNSIS^  ReICHMANN's  DISEASE^  ETC.) 

*  PAGE 

S_vmptomatolog5^ — Differential  Diagnosis  of  the  Forms  of 
Hj'persecretion — Treatment — The  Medicinal  Remedies — 
Alkalies  and  Alkaline  Spring  Waters — An  Excess  of  Or- 
ganic Acids     .........     526 

Lecture  LIL     Round  Ulcer  of  the  Stomach 

^tiolog}^ — The  Incidence  of  Ulcer  as  to  Sex  and  Age — Pa- 
thology —  Sj^mptomatology  —  Complications  —  Sequels  of 
Gastric    Ulcer         ........     533 

Lecture  LIII.     The  Diagnosis  of  Ulcer  of  the  Stomach 

Hemorrhage  from   the   Stomach — The   Diagnosis   from   Ulcer 

of  the  Duodenum — Differential  Diagnosis         .         .         .     543 

Lecture  LIV.     The    Treatment   of    Gastric    Ulcer — 
Erosions  of  the  Stomach 

Treatment,  Prophylactic  and  Curative — Massage— Medicinal 
Measures — Treatment  of  Complications  and  Sequels — 
Erosions  of   the   Stomach         .         .         .      •  .         .         .     549 

Lecture  LV.     Round  Ulcer  of  the  Duodenum 

^Etiology  and  Pathology — The  Symptoms  of  Duodenal  Ulcer — 

Diagnosis — Complications    and    Sequels — Treatment         .     559 

Lecture  LVI.     Tubercular  Ulcerations  in  the  Stom- 
ach AND  Intestines 

Tubercular  Ulcers  of  the  Intestines — Sj^mptomatolog}^ — Diag- 
nosis— Prognosis — Treatment — The  Tuberculin  Treat- 
ment— Dr.  Pottenger's  Method — Hygienic  and  Climatic 
Measures,    etc.         ........     567 

Lecture    LVII.     Syphilis    of    the    Stomach    and    In- 
testines 

Syphilitic  Chronic  Gastritis — Syphilitic  Gastric  Ulcer — Syph- 
ilitic Ulcers  of  the  Intestines — Syphilitic  Neoplasms  of  the 


CONTENTS 


PAGE 


Gastro-Intestinal  Tract — Treatment  of  Syphilitic  Disease 

in  the  Stomach  and  Intestines         .....     578 

Lecture  LVIII.  Intestinal  Ulcers  Generally — Hem- 
orrhage FROM  THE  Stomach  and  Intestines 

Various  Other  Forms  of  Intestinal  Ulceration — Symptoms  of 
Intestinal  Ulcer — Treatment  of  Intestinal  Ulcer — Hemor- 
rhage from  the  Stomach  and  Intestines — Significance  of 
Blood  in  Vomit  or  Stools — The  Source  of  the  Larger  Gas- 
tric Hemorrhages — Less  Frequent  Causes  of  Hematemesis 
— The  Source  of  Blood  Found  in  the  Stools — Blood  in 
both  Vomit  and  Stools — The  Modified  Weber  Test — ^The 
Iron  Test  for  Blood — Treatment  of  Gastro-Intestinal 
Hemorrhage  585 

Lecture  LIX.     Carcinoma  and  Other  Tumors  of  the 

Stomach 

Frequency  and  Incidence  of  Carcinoma — The  Varieties  of  Can- 
cer— The  Secondary  Pathologic  Manifestations — Compli- 
cations, Sequelae,  etc. — Gastrocolic  Fistula — Symptom- 
atology of  Gastric  Carcinoma — Cancer  of  the  Cardia — 
Sarcomas  of  the  Stomach — Benign  Tumors  of  the 
Stomach  .........     602 

Lecture   LX.     The    Diagnosis   of    Carcinoma   of   the 

Stomach 

Histologic  Changes  in  Gastric  Cancer — Carcinomatous  Ulcer 
— The  Differential  Diagnosis  of  Gastric  Cancer  from 
other  Abdominal  Tumors         .         .         .         .         .         .621 

Lecture  LXI.  The  Differential  Diagnosis  between 
Carcinoma  and  Round  Ulcer 

Cancer  of  the  Cardia  Differentiated  from  Ulcer — Chief  Diag- 
nostic Points — Carcinomatous  Ulcer — The  Therapeutic 
Test 630 

Lecture   LXII.     The   Treatment   of   Carcinoma   and 

Other-  Tumors  of  the  Stomach 
Treatment  with  X-Rays — Case  Reported  by  Dr.  W.  J.  Mor- 
ton— Reports  from  Drs.  Einhorn,  Coley,  and  Snow — Early 


CONTENTS 

PAGE 

Diagnosis  Indispensable — Indications  for  an  Exploratory- 
Incision — Operative  Treatment — The  Use  of  the  X-Rays, 
Radium,  etc.,  in  Cancer  of  the  Stomach — Medicinal  and 
Palliative  Treatment — Dietetic  Treatment — Treatment 
of  Accompanying  Gastritis  and  Its  Results — Measures 
against  the  Debility,  etc. — To  Relieve  the  Pain — Treat- 
ment of  Sarcoma  and  Benign  Tumors       ....     636 

Lecture  LXIII.     Tumors  of  the  Intestines 

Carcinoma  and  Sarcoma — .Etiology — Metastases — Pathology 
— Symptomatology — Course  and  Complications — Diag- 
nosis— Differential  Diagnosis  betw^een  Tuberculosis  and 
Carcinoma  of  the  Cecum — Other  Diagnostic  Points — 
Prognosis  and  Treatment — Benign  Tumors  of  the  Intes- 
tines— Treatment    .         .         .         .         .         .         .         .652 

Lecture  LXIV.     Intestinal  Obstruction 

Classification — Dynamic  or  Paralytic  Obstruction — Mechanical 
Obstruction — Invagination — Intussusception  of  Meckel's 
Diverticulum  —  Volvulus  —  Hernia  —  Strangulation  by 
Knotting,  Kinking,  etc. — Obturation,  Obstruction,  Gall 
Stones,  Enteroliths,  Worms,  Hardened  Feces,  Polypi, 
Tumors,  Displaced  Organs,  etc. — Pathology — Differential 
Diagnosis  of  Acute  Ileus — Prognosis — Treatment — 
Chronic  Intestinal  Obstruction — Chronic  Intussusception 
— -Strictures  from  Carcinoma  or  Healed  Ulcers — Tuber- 
cular Ulcers  and  Grovi^ths — Treatment  of  Chronic  In- 
testinal Obstruction         .......     668 

Lecture  LXV.     Acute    Catarrh    of    the    Intestines 
( Enteritis  Acuta) 

Symptomatology — Diagnosis — Treatment — The  Diet        .         .     707 

Lecture  LXVI.     Chronic  Catarrh  of  the  Intestines 
(Enteritis  Chronica) 

Pathology — Symptomatology — Diagnosis — Treatment       .         '715 


contents 

Lecture    LXVII.     Appendicitis,    Its    Symptoms,    Diag- 
nosis, ETC. 

PAGE 

The  Different  Forms  of  Appendicitis — Pathology — Symptoms 
— Diagnosis — Physical  Signs — Clinical  Course — Chronic 
Catarrhal  Appendicitis — The  Prognosis  under  Different 
Methods  of  Treatment 728 

Lecture  LXVIIL     The  Treatment  of  Appendicitis 

The  Radical  Surgical  Method — The  Conservative  Method — 
The  Ochsner  Plan,  or  Surgico-Starvation  Method — 
Ochsner's  Description  of  his  Method — Murphy's  Method 
— Richardson's  Results — Deaver's  Recent  Work — Ochsner's 
Statistics — Deductions  from  the  Foregoing — A  Symposium 
on  Appendicitis — Richardson's  Conservative  View — The 
Treatment  of  Acute  Catarrhal  Appendicitis — Treatment 
of  the  Severer  Forms  of  Acute  Appendicitis — ^The 
Treatment  of  Chronic  Catarrhal  Appendicitis — Report 
of  Author's  Case — Further  Considerations  Regarding 
the  Management  of  Appendicitis — Unfavorable  Condi- 
tions   for    Operation        .......     743 

Lecture  LXIX.     Constipation 

Etiology — The  Differential  Diagnosis  between  Atonic  and 
Spastic  Constipation — The  Stools  in  Atonic  and  Spastic 
Constipation    .         .  .  .  .  .  .  .  .766 

Lecture    LXX.      Constipation,    Continued:    Prognosis 
AND  Treatment 

Penzoldt's  Diet  for  Atonic  Constipation — Changes  of  Climate     774 

Lecture  LXXL     Diarrhea 

Etiology — The  Treatment  of  Diarrhea — Complicating  Condi- 
tions— The  Appendix  often  Involved  in  Diarrhea — The 
Diet  in  Chronic  Diarrhea — The  Nervous  Forms  of  Diar- 
rhea        .         .  .         .  .  .         .  .         .         .     784 


contents 
Lecture  LXXII.     Dysentery 

PAGE 

Definition — Catarrhal  Dysentery — Sporadic  Dysentery — The 
Treatment  of  Catarrhal  Dysentery — Bacillary  Dysentery 
— Secondary  Diphtheritic  Dysentery — Diagnosis  of  Bacil- 
lary Dysentery — Complications  and  Sequels — Treatment 
of  Bacillary  Dysentery — ^Amoebic  Dysentery — Chronic 
Dysentery — The  Pathology  of  Chronic  Dysentery — Com- 
plications— The  Treatment  of  Chronic  Dysentery     .         .     793 

Lecture  LXXIIL  Membranous  Catarrh  of  the  In- 
testines (CoLiCA  Mucosa,  Myxoneurosis  Intes- 

TINALIS    MeMBRANACEa) 

ufEtiology — Diagnosis — Treatment — DieteticTreatment — Form 
of  Diet  Recommended — Comments  on  the  von  Noorden 
Method — The  After-Treatment — Treatment  of  Colica 
Mucosa  in  True  Enteritis         ......     809 

Lecture  LXXIV.  Excessive  Eructation  and  Gastro- 
intestinal Flatulency  in  General 

Belched  Gas  often  from  the  Intestines — Chronic  Appendicitis 
as  a  Source  of  Flatulency — Infection  of  the  Alimentary 
Tract  from  the  Mouth,  Nose,  and  Throat — The  Treat- 
ment  of   Flatulency         .......     822 

Lecture    LXXV.     Gastric    Neuroses,    Secretory    and 

Sensory 

The  Nervous  Secretory  Derangements  of  the  Stomach — Ner- 
vous Hypochlorhydria  or  Gastric  Subacidity — Nervous 
Anacidity  of  the  Stomach — Sensory  Disturbances  of  the 
Stomach:  Gastralgia,  Gastric  Hypersesthesia,  etc. — Gas- 
tric Hyperassthesia — Other  Abnormal  Sensations  in  the 
Stomach — Derangements  of  the  Appetite — Bulimia  and 
Akoria — The  Buccal  Reflex — The  Proper  Food  Ration — 
Anorexia  and  Hyperkoria         ......     830 

Lecture  LXXVI.     The  Motor  Neuroses  of  the 
Stomach 

Spasm  of  the  Entire  Stomach  (Gastrospasm) — Spasm  of  the 
Cardia — The  Treatment  of  Cardiospasm — Spasm  of  the 


CONTENTS 

PAGE 

Pylorus  (Pyloric  Cramp,  Pylorospasm) — Peristaltic  Rest- 
lessness (Hyperperistalsis) — Nervous  Eructations — Ner- 
vous and  Reflex  Vomiting — Treatment  of  Reflex  Vomiting 
— Pernicious  Vomiting  of  Pregnancy — Nervous  Atony  of 
the  Stomach — Insufficiency  of  the  Cardia,  Rumination, 
Regurgitation,  etc. — Insufficiency  of  the  Pylorus       .         .851 

Lecture  LXXVIL  Neuroses  Continued  —  Nervous 
Dyspepsia  (Gastro-Intestinal  Neurasthenia) 

Symptomatology — Diagnosis — Treatment  in  General — Diet — 

Drug  Treatment     .         .         .         .         .         .         .         .871 

Lecture  LXXVIII.     Neuroses  of  the  Intestines 

Enteralgia,  Intestinal  Colic,  Enterospasm  and  Meteorism — 
Tympanites,  or  Flatulency — Peristaltic  Unrest — Atony 
and  Paralysis  of  the  Intestines — Peristaltic  Unrest  of  the 
Intestines — Paralysis  of  the  Intestines — The  Treatment 
of  the  Intestinal  Neuroses — Treatment  of  Peristaltic  Un- 
rest of  the  Intestines — Treatment  of  Paralysis  of  the  In- 
testines   ..........     879 

Lecture  LXXIX.     Diseases  of  the  Rectum  and  Anus 

Examination  of  the  Patient — The  Symptoms  and  Their  Sig- 
nificance— Technique  of  the  Examination — The  Digital 
Examination — Inspection  of  the  Anus — The  More  Impor- 
tant Instruments  Required — The  Rectal  Relations  of  Con- 
stipation— Fecal  Impaction — The  Early  Symptoms — The 
Treatment  —  Hemorrhoids  —  Varieties  —  The  Injection 
Treatment  of  Hemorrhoids — A  Palliative  for  Bleeding — 
Fissure  of  the  Anus — Pruritus  Ani — Abscess — Varieties — 
The  Symptoms — Diagnosis  of  Ischio-Rectal  Abscesses — 
The  Treatment  of  Complications — Fistula  in  Ano — Diag- 
nosis— A  Majority  of  Fistulas  non-Tuberculous — Pro- 
lapse— Etiology — Treatment — Stricture  of  the  Rectum — 
Varieties  and  Etiology — Diagnosis — Treatment — Ulcera- 
tions of  the  Rectum — Varieties  andiEtiology — The  Symp- 
toms— The  Treatment — Benign  Tumors  of  the  Rectum — 


CONTENTS 

PAGE 

— Symptoms — Diagnosis — Treatment — Malignant  Tu- 
mors— The  Etiology — Symptoms — The  Diagnosis — 
Treatment — The    Massey   Method — Sarcoma    .        .        .      892 

Lecture  LXXX.  Bacteria  and  Animal  Parasites  in 
THE  Gastro-Intestinal  Tract 

The  Intestinal  Parasites — Diagnosis  of  the  Ova — Amoeba  Dys- 
enteriae — Ankylostoma  Duodenale — Treatment  of  Round 
and  Tapeworms -931 

Lecture  LXXXL  Gastro-Intestinal  Affections  in 
Relation  to  Other  Diseases 

Anaemia  and  Chlorosis — Influence  of  Displacements  of  the 
Viscera  upon  the  Blood — Influence  of  Constipation  and 
Other  Gastro-Intestinal  Affections — The  Relation  of  the 
Gastro-Intestinal  Functions  to  Tuberculosis — Impaired 
Digestion  Conducive  to  Tuberculosis — Free  HCl  often 
Present — The  Motor  Function  mostly  Depressed — Fre- 
quent Intolerance  of  the  Usual  Remedies — Need  of 
Strengthening  the  Motor  Function — Conclusions — Catar- 
rhal Affections  of  the  Respiratory  Tract — Nervous  De- 
rangements, Neurasthenia,  Insomnia,  etc. — Diseases  of  the 
Liver  and  Genital  Organs — Diseases  of  the  Heart — How 
Digestive  Faults  Injure  the  Heart — Therapeutics  of  Sec- 
ondary Cardiac  Affections — Diseases  of  the  Kidneys  and 
Diabetes — Influence  of  Bright's  Disease  and  Diabetes  on 
Digestion 953 

Lecture  LXXXII.  Arteriosclerosis  and  Its  Relations 
to  the  Affections  of  the  Gastro-Intestinal  Tract 

Arteriosclerosis  of  the  Abdominal  Vessels — Diagnosis — Clinical 
Observations  on  Blood-Pressure  by  the  Author — Proph- 
ylaxis and  Treatment 97^ 

Lecture  LXXXIII.    The  Surgery  of  the  Stomach  and 

Intestines 
Surgery  of  the  Stomach — Gastric  Ulcer — Perigastric  Adhesions 
— Cicatricial  Stenosis  of  the  Cardiac  Opening  of  the  Stom- 
ach— Stenosis  of  Pylorus — Hour-Glass  Stomach — Cancer 


CONTENTS 


PAGE 


and  Sarcoma  of  the  Stomach — Wounds  of  the  Stomach — 
Duodenal  Ulcer — Tuberculosis  of  the  Intestines — Intes- 
tinal Tumors — Intestinal  Obstruction  from  Calculi, 
Intestinal  Concretions,  Intussusception,  Volvulus,  Intes- 
tinal Flexure,  Adhesions  and  Bands,  Meckel's  Divertic- 
ulum, Hernia 986 


LIST    OF    ILLUSTRATIONS 


FIG. 
I. 
2. 
3- 

4- 

5- 
6. 

7- 


10. 

II. 

12. 

13- 

14- 
15- 
i6. 
17- 
i8. 
1 9. 

20. 
21. 
22. 
23- 
24. 
25- 

26. 
27. 
28. 
29. 
30. 

31- 

31a 

31b 

32. 

33 

34- 

35 

36. 

37 

38. 


Cross  section  of  squamous  epithelium  from  mucosa  of  tongue 

Coronal  section  of  the  trunk 

Stomach  in   natural   position 

Posterior   surface   of   the   stomach   and   its   relations     . 
Position  of  organs  in  upper  part  of  abdomen.     Front  view 
Position  of  organs  in  upper  part  of  abdomen.     Back  view 
A   cardiac  gland   from   dog's   stomach     .... 
Pyloric  gland  from   section  of  dog's  stomacli 
Glands  from  cardiac  end  of  stomach     .... 
Glands   from   pyloric   end   of   stomach     .... 
Injected  intestine  showing  central  lacteal  and  capillaries  in 
Glands  and  lymphoid  tissue  from  appendix  vermiformis 
Glands  and  goblet  cells  from  the  colon 
Einhorn's   gastrodiaphane 
Turck's    gyromele 


Electric    gastroscope 

Outlines  of  gastric  tympany 

Reed's   pleximeter 

Flexible  stomach  tube  with  fenestrum  attached 

Flexible   stomach  tube,   with    funnel   attached 

The    Kuttner    aspirator 

Kuttner   aspirator   with  tube  attached 

Burette   for   quantitative   analysis     . 

Yeast.     From  a  photograph 

Bacillus   butyricus       .... 

Sarcinae  ventriculi       .... 

Pathogenic  micro-organisms  of  the  intestines 

Various  crystals  in   feces 

Stool  in  chronic  colitis 

Crystals  of  bismuth   sulphid,   fat-droplets,  etc. 

Microscopic  appearance  of  normal    feces 

Microscopic  appearance  of  test-diet  feces 

Fermentation  tubes   after   Strassburger 

Chair  exercise  for  arm  and  trunk  muscles 

Second  position  of  the  same     . 

Forward  and  backward  body-bending     . 

Rotary  movement  of  the  trunk  while  sitting 

Pulley  exercise  for  arm  and  trunk  muscles 

Same  with  low  attachment  of  the  pulleys 

Central  galvanization   illustrated 


llus 


PAGE 
30 
31 
32 
32 

33 
33 
34 
34 
35 
36 
41 
42 

43 
86 

87 
88 

94 
97 
109 
no 
114 
IIS 
135 
141 


141 
141 
169 
170 
171 
172 
176 
176 
176 
263 
263 
264 
265 
266 
267 
279 


LIST    OF    ILLUSTRATIONS 
FIG. 

39.  The   static   electric   machine 

40.  Herschell-Dean  triphase   apparatus  .... 

41.  Cleaves'  electrode  for  hydro-electric  applications  . 

42.  Rose's  apparatus  for  generating  carbonic  dioxide 

43.  Turck's   apparatus  for   pneumatic  gymnastics 

44.  A   vibrator   .......... 

45.  Li^vage   of   the    stomach.     Inserting   the    tube 

46.  Lavage   of  the   stomach.     Pouring   solution   into    funnel 

47.  Turck's   stomach    sprinkling   tube 

48.  Einhorn's  intragastric  spray  apparatus     .... 

49.  Einhorn's   intragastric    electrode       ..... 

50.  Reed's  intragastric  electrode 

51.  Stomach  of  normal  size     ....... 

52.  The  stomach  dilated,  but  not  displaced  .... 

53.  Area  of  tympany  in  case  of  gastrectasis  with  gastroptosis 

54.  Palpation  of  movable  kidney     ...... 

55.  Splanchnoptosis   with   marked   gastroptosis,    coloptosis,    etc 

56.  Area   of   tympany   in    case    of   gastroptosis     . 

57.  Anomalcras  course  of  first  portion  of  ascending  colon  . 

58.  Elongation   and    displacement   of   sigmoid   flexure 

59.  The  sigmoid  loop  touches  lower  border  of  left  kidney 

60.  Exaggerated   and   displaced    sigmoid   loop 

61.  V-shaped    course    of   the    transverse    colon     . 

62.  Exaggerated  V-shaped  course  of  transverse  colon 

63.  Anomalous    direction    of    transverse    colon     . 

64.  Downward  displacement  of  Hver  and  intestines     . 

65.  Mucoid  and  cystic  degeneration  of  gastric  mucous  membran 

66.  Gastric  catarrh :   fatty   degeneration  of  glands 

67.  Atrophy  of  mucous  membrane  of  stomach  with  polyposis 

68.  Fibrosis  in  gastric   catarrh 

69.  Columnar  cells,  etc.,  in  case  of  chronic  acid  gastritis     . 

70.  Yeast  fungi  and  columnar  epithelium  from  case  of  chronic 

gastritis 

71.  Magnesium  phosphate  crystals  from  stomach  in  case  of 

chlorhydria  

72.  Pyloric  end  of  stomach,  showing  ulcer  on  posterior  wall 
7^.  Perforated   chronic   ulcer  .... 

74.  Carcinomatous    ulcer    of    duodenum 

75.  Cancer  of  posterior   wall   of   stomach     . 

76.  Diffuse    cancer   of   stomach 
yy.  Boas-Oppler    bacilli     ..... 

78.  Cancer   of  the   pylorus       .... 

79.  Cancer    of   the    cardia         .... 

80.  Section  from  carcinoma  of  the  pylorus     . 

81.  Ulcerating    carcinoma    of    the    rectum     . 

82.  Intussusception    of   the   jejunum 


PAGE 

282 
284 
289 
297 
299 
306 
316 
.317 
318 
319 
32s 
324 
398 
399 
401 
422 
431 
434 
445 
447 
448 

449 
450 
451 
452 
458 
487 
489 
490 
491 
508 


acid 


hyper- 


LIST    OF    ILLUSTRATIONS 
FIG.  PAGE 

83.  Ileocolic   intussusception 674 

84.  Invaginated    Meckel's    diverticulum 677 

85.  (a)   Ileum  with   Meckel's  diverticulum,     (b)   Diverticulum  in- 

vaginated   into    ileum 678 

86.  Secondary  intussusception  of  ileum  due  to  invaginated  divertic- 

ulum       679 

87.  Meckel's   diverticulum   invaginated  into   its   own   lumen     .         .  679 

88.  Invaginated   Meckel's   diverticulum   with   complication         .         .  680 

89.  Two   stages  of  complicated  invagination  of  Meckel's  divertic- 

ulum       681 

Invagination  beginning  above  the  diverticulum    .....  682 

Knotting  of  loops  of  the   ileum 685 

Constriction  of  small  intestine  by  omental  adhesion     .         .         .  686 

Various  forms  of  constriction  by  club-shaped  diverticulum     .  688 

Tuberculous  stricture  of  ileum      . 702 

Colloid  cancer  and  tubercle 703 

Tuberculous   stricture'  of  ileum 704 

Amoeba  dysenterige 803. 

The  nerves,  blood-vessels,  and  lymphatics  of  stomach      .        .  826 

Martin's   conical   speculum       ........  898 

Bodenhamer's  bivalve   speculum 89S 

Tuttle's  pneumatic  proctoscope 8^9 

Martin's  fistula  knife .  916 

Kelly's   dilator   for   female  urethra* 921 

Short  electrodes  for  external  use 929 

Long  rectal  electrode  for  internal  use 929 

The  more  common   intestinal   parasites 939 

Amoeba  coli  mitis  or  vulgaris 941 

Ankylostoma    duodenale •         .         .  943 

Eggs  of  Uncinaria  americana  from  feces 944 

Trichina    spiralis .         .  950 

Trichocephalus  dispar 951 

Ovum  of  Trichocephalus  dispar    .        .        .        .        .        .        .  952 


PART    I 

anatomic,  physiologic, 
:hemic,  and  diagnostic  data 


DISEASES  OF  THE  STOMACH 
AND  INTESTINES 

LECTURE  I 
ANATOMY  OF  THE  DIGESTIVE  TRACT 

For  the  proper  recognition  and  treatment  of  enlargements, 
contractions,  or  displacements  of  the  digestive  organs,  and, 
indeed,  of  their  disorders  generally,  it  is  important  to  have  a 
perfect  understanding  of  their  normal  size  and  position  as 
well  as  of  their  relation  to  each  other.  Without  attempting 
to  go  fully  into  the  anatomy  of  these  organs  I  will  present  to 
you  a  brief  summary  of  its  essentials.  Other  elementary  data, 
especially  physiologic,  will  also  be  useful.  Those  of  you  who 
desire  to  study  the  subject  thoroughly  will  of  course  refer  to 
comprehensive  works  on  the  anatomy,  histology,  physiology, 
and  physiologic  chemistry  of  the  digestive  system,  and  the 
following  account  can  therefore  be  very  much  condensed. 

The  digestive  tract  begins  with  the  mouth  and  pharynx  and 
the  adjacent  salivary  glands.  The  tongue  and  teeth  also  play 
a  large  part  in  the  processes  of  digestion. 

The  pharynx  is  behind  the  nose  in  its  upper  part  and  behind 
the  mouth  in  its  lower  part,  these  cavities  opening  directly  into 
it.  It  extends  from  the  base  of  the  skull  above  to  the  lower 
part  of  the  cricoid  cartilage  opposite  the  sixth  cervical  vertebra. 
At  this  point  it  joins  the  esophagus,  forming  with  the  latter  a 
continuous  muscular  tube  lined  with  mucous  membrane.  It 
measures  about  45^2  inches  (11.3  cm.)  from  above  downward. 
It  is  widest  opposite  the  cornua  of  the  hyoid  bone  and  nar- 
rowest at  its  point  of  juncture  with  the  esophagus.     In  its 


30       ANATOMIC,    PHYSIOLOGIC,   CHEMIC,   DIAGNOSTIC   DATA 

lower  part  the  cavity  is  entirely  obliterated,  the  walls  being  in 
contact  except  during  the  act  of  swallowing. 

The  esophagus  extends  from  the  lower  end  of  the  pharynx 
to  the  cardiac  orifice  of  the  stomach.  Its  length  is  from  9  to 
10  inches  '(22.86  to  25.4  cm.).  It  is  narrowest  at  its  junction 
with  the  lower  end  of  the  pharynx  and  is  again  constricted 
where  it  passes  through  the  diaphragm  to  enter  the  stomach 
opposite  the  upper  border  of  the  eleventh  dorsal  vertebra.     At 


Fig.  I. — Cross  section  of  squamous  epithelium  from  the  mucosa 
of  the  tongue. 

its  beginning,  opposite  the  sixth  cervical  vertebra,  it  lies  in  the 
middle  line  in  front  of  the  vertebral  column.  It  then  follows 
the  cer\'ical  and  dorsal  curves  of  the  vertebral  column,  but 
curves  also  to  the  left  in  the  neck,  and  finally,  after  passing 
along  the  right  side  of  the  thoracic  aorta,  turns  again  to  the 
left  in  passing  through  the  diaphragm. 


ANATOMY    OF    THE    DIGESTIVE    TRACT 


31 


Abdominal  Cavity. — In  this  are  included  the  stomach  and 
small  and  large  intestines  as  well  as  the  liver  and  pancreas. 
All  of  these  digestive  organs  as  well  as  the  spleen,  which  is 
included  among  the  latter  by  some  writers,  and  the  omentum, 
kidneys,  and  various  other  structures  are  invested  with  a  thin 


Fig.  2. — Coronal  section  of  the  trunk  (from  a  model  in  the  mu- 
seum, University  College),  i,  heart  ;  2,  stomach  in  transverse 
section  ;  3,  gall-bladder  ;  4  and  6,  duodenum  ;  5,  liver  ;  7,  colon  ; 
8,  diaphragm  ;  9,  lungs. — From  Sidney  Martin's  "  Diseases  of 
the  Stomach." 


serous  membrane  called  the  peritoneum.  This  lines  the  ab- 
dominal walls  and  covers  the  viscera,  forming  a  closed  sac. 
The  stomach  is  a  pear-shaped  pouch  lying  in  the  epigastrium 
and  left  hypochondriac  regions.  About  one-sixth  only  of  It 
is  on  the  right  of  the  median  line.  When  normal  its  size  is 
about  12  inches  (30.48  cm.)  long  and  4  to  5  inches  (10.16 
cm.— 12.70  cm.)  wide  in  vertical  diameter,  the  antero-posterior 
diameter  being  a  little  less.     It  weighs  4  to  5  ounces  (ii3-4  to 


)2       ANATOMIC,   PHYSIOLOGIC^  CHEMIC^  DIAGNOSTIC  DATA 


141.75  grms.)  and  in  health  its  average  capacity  is  a  little 
more  than  three  pints  (1600  to  1700  c.  c.  according  to 
Ewald).  The  stomach  has  two  orifices:  the  cardiac  where 
the  esophagus  enters  it,  and  the  pyloric  where  it  joins  the 
duoderAim;  also  two  borders,  the  greater  and  lesser  curva- 
tures, and  two  surfaces,  the  anterior  and  posterior.  Its  large 
end  is  called  the  fundus  and  its  smaller  end  the  pyloric 
portion.  The  cardiac  opening  lies  about  4  inches  (10.16  cm.) 
behind  the  seventh  left  chrondrosternal  juncture,  at  about  the 


Fig.  3. — Stomach  in  natural  posi- 
tion, showing  structures  in  con- 
tact with  the  anterior  surface. 
The  circle  represents  the  position 
of  the  duodeno-jejunal  flexure. — 
T/^ane. 


Fig.  4. — Posterior  surface  of  the 
stomach  and  its  relations.  St= 
supra-renal  body.  Spl.fl.=splenic 
flexure  of  colon.  The  circle  shows 
position  of  the  duodeno-jejunal 
flexure. —  Thane. 


level  of  the  eleventh  dorsal  vertebra.  It  is  a  little  above  and 
behind  the  apex  of  the  heart.  It  is  fixed  in  its  position  there 
by  the  phrenico-gastric  ligaments  and  the  esophagus. 

^  The  pyloric  is  lower  and  nearer  the  surface  than  the  car- 
diac end  and  is  very  movable.  It  is  normally  to  the  right  of 
the  median  line  between  the  sternal  and  parasternal  lines  oppo- 
site the  upper  border  of  the  first  lumbar  vertebra,  and  between 
1  Holzknecht  and  others  who  have  studied  numerous  stomachs  in  healthy 
young  persons  by  means  of  the  x-ray,  now  hold  that  the  pylorus  is  lower 
than  here  pictured  and  described. 


ANATOMY    OF    THE    DIGESTIVE    TRACT 


33 


Lung 


Outline  of 
Stomach 


Liver 

Gall 
Bladder 

Umbilicus 
Colon 


Fig.  5. — Position  of  the  organs  in  the  upper  par.t  of  the  abdomen.  Front 
view.  The  highest  points  of  the  liver  and  fundus  are  somewhat  too 
high  in  the  figure. — After  Luschka} 


Outline  of_ 
Stomach 


Spleen 


Left 
Kidney 


Descending 
Colon 


Lung 


Liver 


—Duodenum 
Pa7icreaS 

Ascending 

Colon 


Fig.  6. — Position  of  the  organs  in  the  upper  part  of  the  abdomen.     Back 
view. — After  Ltisckka. 

1  H.    von   Luschka,  "  Die   Lage    der    Bauch-Organe    des   Menschen.' 
Carlsruhe,  1873,  Plates  I  and  II. 


34       ANATOMIC,   PHYSIOLOGIC,  CHEMIC,  DIAGNOSTIC  DATA 


Fig.  7. — A  cardiac  gland  from  the  dog's 
stomach  (Klein  and  Noble  Smith),  d, 
uioatri  of  the  gland;  b,  fundus  of  one 
of  the  tubules;  e,  epithelium;  /,  parie- 
tal cells;  <r,  central  cells.— /'r<?;;^  Sidney 
Martin's  "  Diseases  of  the  Stomach. 


Fig.  8.— Pyloric  gland 
from  a  section  of  the 
dog's  stomach  ;  in, 
mouth;  n,  neck. — Eb- 
stein. 


ANATOMY    OF    THE    DIGESTIVE    TRACT 


35 


the  ends  of  the  seventh  ribs  in  front.  It  is  a  httle  to  the  right  of 
the  tip  of  the  ensiform  cartilage,  between  the  latter  and  the 
edge  of  the  ribs.  The  lesser  curvature  "is  3  to  5  inches  (7.62 
cm.— 12.7  cm.)  long,  having  a  concavity  looking  upward  and 
to  the  right,  and  lies  through  most  of  its  course  normally 
in  apposition  with  the  left  edge  of  the  vertebral  column.  The 
greater  curvature  begins  a  little  to  the  left  of  the  sixth  costo- 
sternal  articulation  and  is  four  times  as  long  as  the  lesser  cur- 
vature. It  rises  to  the  fourth  intercostal  space,  that  is  a  little 
above  the  level  of  the  apex  of  the  heart,  and  thence  follows  a 
nearly  circular  direction  downward  and  to  the  left,  to  a  point 


^^' 

'  "1 

d 

i  ..'■ 

^^ 

•.» 

^B 

wm^-} 

^^^mt 

s-<^i 

^^2^^^™^ 

^^s^l 

^^I'i^lr^fc'^'jl^-ii^*:^^^, >■  ' .  .^M 

mM 

"  '^:/'5j- 

■'■,■:#•-? 
J  '  ,,^# 

^l^*":.^:.;:::] 

% 

!.*&• 

":-•;/*• 

lii^ 

^teiid 

^B 

'■  ;  i-,--?-.'^:;-?.-'^ 

('':J<',V-'-:'s::{ii'^^sS 

■  '   ^ifaasxsB^^fsl^^SMKIIIl^S 

K;*^ 

^^^ 

^"^^^^F 

^ 

;='v::";>v'j^ 

p^^^^B 

^^^^^v^ 

^ 

'  —  -•  '"^_ .^s. 

j^ 

Fig.  9. — Glands  from  the  cardiac  end  of  the  stomach. 

near  the  lower  border  of  the  seventh  rib,  where  it  curves  to  the 
right  across  the  middle  line,  normally,  to  a  point  a  little  lower 
than  midway  between  the  tip  of  the  ensiform  cartilage  and  the 
umbilicus,  and  terminates  at  the  pylorus.    The  diameter  of  the 


$6       ANATOMIC,    PHYSIOLOGIC,   CHEMIC,  DIAGNOSTIC  DATA 


pyloric  opening  is  about  one-half  inch  (1.3  cm.),  this  being  the 
narrowest  part  of  the  digestive  canal. 

The  gastric  glands  comprise  three  varieties  of  secreting 
cells,  viz.:  i,  the  cylindric  cells  which  form  the  mucous  layer 
of  the  lining  membrane  and  extend  part  of  the  way  into  the 
gland  ducts :  2,  cuboidal  cells  with  a  granular  protoplasm  and 
spherical  nucleus  called  by  Heidenhain  chief  or  central  cells; 
and  3,  the  border,  parietal  or  oxyntic  cells.     The  first  secrete 


\  •  - 


Fig.   10. — Glands  from  pj'loric  end  of  stomach. 


mucus  only,  so  far  as  known;  the  second,  according  to  Heiden- 
hain and  others,  secrete  the  ferments  of  the  gastric  juice, 
pepsinogen  and  rennin  zymogen ;  and  the  third  are  now  be- 
lieved, upon  the  same  authority,  to  secrete  the  HCI  only.  The 
border  cells  which  furnish  HCI  are  found  chiefly  in  the  middle 
part  of  the  stomach  with  a  less  number  in  the  fundus,  and  the 
chief  or  central  cells,  which  furnish  the  gastric  ferments,  pre- 
dominate  in  the  pyloric  region;    indeed,   according  to   some 


ANATOMY    OF    THE    DIGESTIVE    TRACT  37 

authorities,  these  are  the  only  secreting  cells  in  the  pyloric 
portion,  though  both  kinds  of  cells  exist  in  the  gland  tubules 
of  the  fundus. 

THE   MINUTE   ANATOMY  OF   THE   STOMACH 

The  minute  anatomy  of  the  stomach  was  exhaustively 
studied  by  Mall  in  a  paper  published  in  vol.  i.  of  the  Johns 
Hopkins  Reports,  entitled  "  The  Vessels  and  Walls  of  the 
Dog's  Stomach,"  and  I  cannot  do  better  than  reproduce  here 
the  summing  up  which  he  therein  makes  of  his  most  important 
investigations : 

Conclusions. — i.  "  From  a  histologic  standpoint  the  mu- 
cous membrane  of  the  stomach  may  be  divided  into  three 
zones — the  pyloric,  with  no  border  cells;  the  middle,  with 
many  border  cells ;  and  the  fundus,  with  but  few  border  cells. 

2.  "  Digestion  of  the  different  portions  of  the  mucous 
membrane  with  weak  HCl  shows  that  the  middle  zone  digests 
most  easily,  the  fundus  less  quickly,  and  the  pyloric,  as  a  rule, 
not  at  all.  Assuming  that  the  rapidity  of  digestion  of  the 
different  portions  is  in  proportion  to.  the  quantity  of  pepsin 
present,  it  makes  it  probable  that  most  pepsin  is  formed  in 
the  middle  zone.  Although  it  has  been  proved  that  pepsin 
is  formed  in  glands  which  do  not  contain  border  cells,  in  gen- 
eral it  may  be  stated  that  the  amount  of  pepsin  formed  by 
the  different  glands  is  in  proportion  to  the  number  of  border 
cells. 

3.  "  The  degree  of  acidity  of  the  mucous  membrane  is  In 
proportion  to  the  number  of  border  cells  present.  It  is  reason- 
able to  suppose  that  the  formation  of  acid  in  any  portion  of 
the  stomach  aids  materially  in  the  formation  of  pepsin  in  the 
same  part.  This  is  very  essential,  because  acid  favors  the 
formation  of  pepsin  from  pepsinogen.  Since  border  cells  are 
only  with  the  greatest  difficulty  digested  in  acid,  we  cannot 
ascribe  to  them  the  power  to  secrete  pepsin;  and  since  the 
morphology  of  the  central  cells  varies  during  digestion  and 
rest,  and  they  are  so  easily  digested  upon  the  addition  of  acid, 


38       ANATOMIC,   PHYSIOLOGIC^  CHEMIC^  DIAGNOSTIC  DATA 

we  must  conclude  with  Heidenhain  that  the  former  are 
probably  concerned  in  the  production  of  acid  and  the  latter 
in  the  production  of  pepsin, 

4.  "  When  the  stomach  is  forcibly  distended  it  is  found  that 
the  dilatation  is  mostly  at  the  expense  of  the  fundus.  This 
seems  also  to  be  the  case  when  the  stomach  is  naturally  filled 
with  food.  Although  the  middle  zone  is  practically  not 
stretched  when  the  stomach  is  filled,  distention  seems  to  favor 
circulation  through  this  part,  because  the  blood-vessels  are 
more  easily  injected  in  a  moderately  distended,  than  in  an 
empty,  stomach. 

5.  "  In  the  intestine  it  is  found  that  the  longitudinal  and 
circular  muscle-fibers  are  antagonistic.  In  the  stomach  the 
pyloric  valve  is  closed,  after  the  muscle-cells  are  dead,  by  a 
fold  of  mucous  membrane  being  thrown  into  the  lumen.  This 
may  take  place  in  a  living  stomach.  A  contraction  of  the 
circular  muscle  tends  to  strengthen  this  valve,  while  the  con- 
traction of  the  longitudinal  muscle  tends  to  weaken  it,  because 
with  the  contraction  of  the  longitudinal  muscle  there  is  always 
an  accompanying  relaxation  of  the  circular  muscle.  Under 
ordinary  circumstances  it  seems  as  though  the  stomach  reduced 
its  lumen  by  simultaneous  contraction  of  both  longitudinal 
and  circular  muscle-fibers.  What  complex  motions  take  place 
during  peristalsis  are  absolutely  unknown.  It  is,  however,  a 
remarkable  fact  that  a  bundle  of  the  circular  fibers  (oblique 
fibers)  are  parallel  with  the  longitudinal  fibers,  which  are 
increased  in  number  in  the  middle  zone.  A  solution  of  this 
problem  seems  within  the  range  of  experimentation. 

6.  "  The  Blood-vessels  of  the  Stomach. — The  celiac  axis 
supplies,  besides  the  stomach,  also  the  spleen  and  the  liver. 
With  a  given  pressure  within  the  aorta,  variation  in  the  resist- 
ance in  the  capillaries  of  the  spleen  and  the  liver  will  have  a 
marked  effect  upon  the  circulation  through  the  stomach.  The 
portion  of  the  stomach  (middle  zone)  supplied  by  the  gastric 
artery  is  to  a  less  extent  under  the  control  of  these  side  influ- 
ences than  is  that  which  is  supplied  by  arteries  arising  from  the 


ANATOMY    OF    THE    DIGESTIVE    TRACT  39 

main  branches  to  the  spleen  and  to  the  hver.  It  must  be  again 
stated  that  there  are,  in  all  probability,  many  other  influences 
which  play  most  important  parts  in  the  distribution  of  blood. 

7.  "  Around  the  two  curvatures  of  the  stomach  there  is  a 
complete  circle  of  anastomosis,  which  has  a  tendency  to  equal- 
ize the  pressure  in  the  arteries  penetrating  the  muscle-walls. 
But  the  anastomoses  arising  therefrom  have  only  a  tendency 
to  make  gradual  gradations,  and  not  an  equal  pressure 
throughout.  The  additional  set  of  anastomoses  within  the 
submucosa  are,  again,  not  sufficient  to  equalize  the  flow 
throughout  the  whole  mucosa.  After  ligating  arteries,  as  well 
as  by  examining  the  mucous  membrane,  during  digestion  and 
rest,  it  is  found  that  no  sharp  lines  can  be  drawn. 

8.  "  The  blood-vessels  are  arranged  in  such  a  manner  that 
from  any  portion  of  the  submucosa  about  one-fourth  of  the 
blood  may  go  to  the  muscle-coats  and  three-fourths  to  the 
mucosa.  It  is  therefore  probable  that  when  the  flow  is  poured 
to  one  side  it  is  diminished  to  the  other,  and  vice  versa.  There 
is,  however,  a  tendency  to  equalize  this  by  the  submucous 
anastomoses. 

9.  "  Since  there  is  but  one  set  of  arteries  to  the  mucosa, 
there  must  be  but  one  sort  of  circulation,  which  may  vary  in 
degree  only,  ^^"ithin  the  mucosa  the  arrangement  is  such  that 
the  portion  of  the  gland  which  is  deepest  receives  the  blood 
richest  in  O.  The  mucous  membrane,  omitting  the  muscularis 
mucosse,  lies  between  two  venous  plexuses.  Contraction  of  the 
muscle-fibers  between  the  glands  and  those  of  the  muscularis 
mucosse  should  diminish  the  volume  of  the  mucosa.  This 
would  have  a  tendency  to  empty  the  glands,  as  well  as  to  press 
blood  from  the  two  venous  plexuses,  especially  the  lower. 
WHiether  or  not  there  is  a  force  within  the  mucosa  which  can 
augment  the  circulation  seems  at  present  impossible  to  deter- 
mine by  experiment.  The  arangement  of  the  parts  is  very 
suggestive. 

10.  "  The  Veins  and  Lymphatics. — The  rich  plexus  of 
veins    within    the    submucosa    is    sufficiently    large    to    hold 


40       ANATOMIC,    PHYSIOLOGIC^   CHEMIC^  DIAGNOSTIC  DATA 

a  considerable  quantity  of  blood.  Tbis  must  be  the  case 
when  the  valves  within  the  veins  coming  from  the  stomach 
are  temporarily  closed.  When  the  valves  are  closed,  a  con- 
traction of  the  circular  muscle  is  sufficient  to  drive  all  the  blood 
from  the  underlying-  veins.  It  is  therefore  possible  that  a 
rhjfthmical  contraction  in  any  part  of  the  stomach  may  favor 
the  circulation  through  its  walls. 

11.  "  The  arrangement  of  the  lymphatics  is  much  the  same 
as  that  of  the  veins,  and  the  foregoing  consideration  (lo) 
applies  equally  well  to  them.  AVhen  we  consider  the  resistance 
to  be  overcome  while  the  lymph  passes  through  so  many  net- 
works before  the  cisterna  chyli  is  reached,  it  makes  it  plausible 
to  state  that  the  circulation  is  favored  by  muscular  contraction. 

12.  "  Since  the  blood  which  leaves  the  stomach  must  pass 
through  the  capillaries  of  the  liver,  it  is  necessary  that  it  be 
constantly  under  a  comparatively  high  pressure.  This  pressure 
is  also  dependent  upon  the  spleen  and  the  intestine.  If  the 
pressure  is  high,  a  regurgitation  into  the  stomach  is  impossible 
on  account  of  the  presence  of  valves. 

13.  "  In  a  stomach  in  which  the  vessels  are  all  equally  dis- 
tended the  rapidity  of  circulation  in  the  celiac  axis  would  be 
263  times  that  in  the  capillaries.  The  area  of  the  section  of 
the  celiac  axis  is  0.0592  square  cm.;  the  immediate  branches 
to  the  stomach,  0.0348  square  cm. ;  to  the  spleen  and  liver, 
0.0244  square  cm.  All  the-capillaries  of  the  stomach :  mucosa, 
6.4524  square  cm.;  muscle-coats,  2.7214  square  cm.;  total, 
9.1738  square  cm.;  9.I738-^o.0348=263. 

"  A  like  estimation  shows  that  the  rapidity  of  circulation 
in  all  the  capillaries  is  1-63  of  that  in  the  arteries  penetrating 
the  muscle-walls;  while  if  the  capillaries  of  the  muscle-walls 
are  excluded,  the  rapidity  in  the  capillaries  of  the  mucosa  rises 
to  1-44. 

"  Considering  the  glands  on  an  average  0.05  cm.  long  and 
0.003  1-3  cm.  in  diameter,  excluding  the  necks,  the  area  of 
all  the  glands  would  be  8671  square  cm.,  or  thirty-eight  times 
the  area  of  mucous  membrane.    A  like  estimation  of  the  capil- 


ANATOMY    OF    THE    DIGESTIVE    TRACT 


41 


laries,  considering  each  capillary  0.04  cm.  long,  gives  for  them 
a  total  area  of  17 18  sc[uare  cm.,  or  7^  times  the  mucous  sur- 
face. The  secreting  surface  is  five  times  that  of  the  blood- 
supply."      (See  Fig.  98,  page  826.) 

THE  ANATOMY   OF   THE    INTESTINES,   LIVER,    ETC. 

The  intestinal  canal  is  about  30  (914.4  cm.)  feet  long,  ex- 
tending from  the  pylorus  to  the  anus.  About  25  feet  or 
upwards  of  four-fifths  of  it  constitute  the  small  intestine — the 


Fig.  II. — Injected  intestine  showing  central  lacteal  and  arrange- 
ment of  capillaries  in  villus. 

duodenum,   jejunum,    and   ileum — the   remainder  comprising 
the  cecum,  colon,  and  rectum. 

The  duodenum,  10  to  12  inches  (25.40  cm.— 30.48  cm.),  is 
the  widest  part  of  the  small  intestine,  being  i^  to  2  inches 
(3.84  cm.— 5.08  cm.)  in  diameter.  It  curves  underneath  the 
pancreas  and  lies  behind  the  tranverse  colon.     It  is  the  most 


42       ANATOMIC,    PHYSIOLOGIC,   CHEMIC,  DIAGNOSTIC  DATA 

fixed  part  of  the  small  intestine,  though  its  first  portion,  about 
2  inches  (5.08  cm.)  long,  is  more  movable  than  any  of  the 
Other  four  parts  into  which  it  is  usually  divided.  The  remain- 
der of  the  small  intestine — including  the  jejunum  and  ileum — 
follows  .^no  definite  or  constant  course,  its  folds  appearing  now 
here  and  now  there,  and  ends  at  the  juncture  with  the  cecum 
in  the  right  iliac  fossa,  the  entrance  being  guarded  by  the  ilio- 
cecal  valve. 


Fig.  12. — Glands  and  lymphoid  tissue  from  the  appendix  vermiformis. 


The  cecum,  or  head  of  the  colon,  is  about  2^  (6.35  cm.) 
inches  long  by  3  inches  (7.62  cm.)  in  breadth.  It  gives  origin 
to  the  appendix  vermiformis,  which  usually  comes  off  on  the 
inner  and  posterior  side  near  the  ilio-cecal  valve  and  varies  in 
length  from  i  to  6  inches  (2.54  cm. --i 5.24  cm.)  averaging 
about  4  inches   (10.16  cm.).     It  varies  much  also  in  width. 


ANATOMY    OF    THE    DIGESTIVE    TRACT 


43 


but  averages  about  one-fourth  inch  (.63  cm.).  The  appendix 
is  most  frequently  twisted  upon  itself  and  usually  points  to- 
ward the  spleen  lying  between  the  end  of  the  ileum  and  its  mes- 
entery, but  sometimes  lies  behind  the  cecum,  ascending  parallel 
with  it. 

The  colon  includes  the  ascending,  transverse,  and  descend- 
ing portions.    The  first  and  third  usually  have  a  vertical  course 


Fig.  13. — Goblet  cells  and  glands  from  the  colon. 

in  the  adult,  and  the  second  a  nearly  horizontal  one,  but  has 
several  curves,  including  a  marked  convolution  near  its  left 
flexure.  The  usual  length  of  the  ascending  portion  from  the 
cecum  to  the  hepatic  flexure  is  8  inches  (20.32  cm.).  The 
transverse  portion  averages  20  inches  (50.80  cm.)  in  length, 
but  varies  greatly  in  different  cases.  It  is  also  the  most  mov- 
able portion  of  the  colon  and  is  very  frequently  displaced 
downward.  The  descending  portion  from  the  splenic  flexure 
to  the  beginning  of  the  sigmoid  flexure  is  usually  Sy^  inches 


44       ANATOMIC,   PHYSIOLOGIC,    CHEMIC,   DIAGNOSTIC  DATA 

(21.62  cm.).  This  is  the  most  fixed  part  of  the  colon.  The 
ascending  colon  is  somewhat  narrower  than  the  cecum  and 
both  the  transverse  and  descending  portions  are  smaller  than 
the  ascending.  The  transverse  portion  of  the  colon  is  usually 
in  apposition  with  the  stomach,  having  its  convexity  forward 
as  w*ell  as  slightly  upward  under  normal  conditions. 

The  sigmoid  flexure  begins  at  the  termination  of  the 
descending  colon  in  the  left  iliac  fossa,  and  curving  to  the 
right  toward  the  middle  line,  joins  the  rectum  at  the  point 
where  the  meso-rectum  ceases,  opposite  the  third  sacral  seg- 
ment in  the  median  line.  The  sigmoid  loop  averages  173/2 
inches  (44.48  cm.)  in  length  and  lies  mostly  in  the  pelvis. 

The  rectum,  beginning  at  the  termination  of  the  sigmoid,  is 
usually  divided  arbitrarily  into  three  portions,  the  first  portion 
according  to  that  division  being  included  here,  following 
the  description  of  Morris,  in  the  sigmoid  loop.  The  re- 
maining portions  constitute  the  rectum  proper  and  extend 
from  the  third  piece  of  the  sacrum  to  the  anus.  The  first  of 
these  portions  follows  the  course  of  the  sacrum  and  cocc5'x 
terminating  at  the  tip  of  the  latter,  and  is  3^  inches  (8.92 
cm.)  long;  the  second  (formerly  called  the  third)  extending 
thence  to  the  anus,  turns  backward  and  downward  and  is  about 
i/^  (3-84  cm.)  inches  long. 

The  cecum,  transverse  colon,  and  sigmoid  flexure  are  wholly 
covered  by  the  peritoneum;  the  second,  or  lowest,  portion  of 
the  rectum  has  no  peritoneal  attachment  at  all. 

Structure  of  the  Stomach  and  Intestines. — The  walls  of  the 
stomach  as  well  as  of  the  small  and  large  intestine  comprise 
four  coats,  a  peritoneal  or  serous,  a  muscular,  a  submucous, 
and  a  mucous  coat.  In  the  stomach  the  muscular  coat  consists 
of  three  layers,  a  longitudinal,  a  circular,  and  an  oblique.  In 
the  intestines  the  muscular  coat  has  two  layers,  an  external 
longitudinal  and  an  internal  circular  la3^er,  the  latter  being  the 
thicker  of  the  two.  The  mucous  layer  in  both  stomach  and 
intestines  is  lined  with  cylindric  epithelium.  On  the  other 
hand,  the  mucous  membrane  in  the  esophagus,  pharynx,  and 


ANATOMY    OF    THE    DIGESTIVE    TRACT  45 

mouth  is  covered  by  a  stratified  squamous  epithelium.  The 
mucous  membrane  in  the  upper  respiratory  tract  is,  for  the 
most  part,  hned  with  ciHated  columnar  epithelium.  The  com- 
paratively small  olfactory  region  in  the  nose  has  an  unciliated 
columnar  epithelium.  Unciliated  columnar  epithelial  cells, 
therefore,  found  in  the  vomit  or  wash  water  of  the  stomach 
in  any  considerable  numbers,  must  have  had  their  origin  in  that 
viscus  except  wdien  there  has  been  a  possibility  of  regurgitation 
from  the  duodenum;  squamous  or  ciliated  columnar  epithelial 
cells,  found  in  fluids  coming  from  the  stomach,  may  be  safely 
declared  to  have  had  their  origin  in  the  regions  above  and  to 
have  been  swallowed. 

The  liver  is  situated  on  the  right  side  of  the  abdominal 
cavity,  directly  underneath  the  diaphragm,  occupying  the  right 
hypochondriac  and  epigastric  regions  and  extending  commonly 
into  the  left  hypochondriac  region.  In  front  it  is  in  apposition 
with  the  fifth,  sixth,  seventh,  eighth,  and  ninth  costal  cartil- 
ages, and  to  the  left  it  is  in  contact  with  the  anterior  abdominal 
wall  below^  the  sternal  notch  (Morris).  On  the  right  side  it 
extends  from  the  seventh  to  the  eleventh  rib.  Its  posterior 
surface  is  opposite  the  ninth,  tenth,  and  eleventh  dorsal  verte- 
brae. It  is  a  movable  organ,  sinks  with  each  inspiration,  and 
is  liable  to  be  permanently  displaced,  especially  downward.  A 
deep  inspiration  in  the  standing  position  forces  the  lower  bor- 
der below  the  ribs,  but  when  the  patient  is  recumbent  the 
anterior  border  is  usually  half  an  inch  above  the  last  rib.  At 
the  left  it  extends  to  a  point  i^^  inches  (3.84  cm.)  beyond  the 
left  border  of  the  sternum  at  the  level  of  the  fifth  rib.  In 
front,  in  the  median  line,  its  lower  border  is  half-way  between 
the  xiphoid  cartilage  and  the  umbilicus.  Its  upper  border,  hav- 
ing a  slight  concavity  upw^ard,  reaches  in  the  mammary  line 
on  the  right  side  to  the  level  of  the  fifth  rib.  The  under  sur- 
face of  the  left  lobe  is  directl}^  over  the  cardiac  end  and  a  part 
of  the  anterior  wall,  of  the  stomach.  The  right  lobe  covers 
the  right  kidney  and  the  hepatic  flexure  of  the  colon,  as  well 
as  the  descending  second  part  of  the  duodenum.    The  quadrate 


46       ANATOMIC,    PHYSIOLOGIC^   CHEMIC^  DIAGNOSTIC  DATA 

lobe  of  the  liver  is  over  the  pyloric  end  of  the  stomach  and  the 
first  ascending  part  of  the  duodenum. 

The  pancreas  lies  transversely  across  the  body,  behind  the 
stomach,  in  the  epigastric  and  left  hypochondriac  regions  oppo- 
site the  first  and  second  lumbar  vertebrae.  It  measures  usually 
5  to  6  inches  in  length  (12.20  to  19.24  cm.)  and  is  half  an  inch 
to  one  inch  thick  (1.27  to  2.54  cm.).  Its  weight  is  from  25^ 
to  3^  ounces  {yy.yz  to  108.82  grms.).  The  pancreas  has 
commonly  been  divided  into  four  portions :  head,  neck,  body, 
and  tail;  the  head  being  at  the  right  end,  around  which  the 
second  part  of  the  duodenum  curves,  and  the  tail  at  its  left 
extremity  where  it  comes  into  contact  with  the  lower  part  of 
the  inner  surface  of  the  spleen.  The  anterior  surface  of  the 
pancreas  is  somewhat  concave,  corresponding  with  the  con- 
vexity of  the  posterior  surface  of  the  stomach,  with  which  it 
is  in  contact.  The  posterior  surface  is  in  apposition  with  the 
aorta,  the  superior  mesenteric  vessels,  and  the  crura  of  the 
diaphragm.  These  various  structures  separate  the  pancreas 
from  the  spine.  The  left  kidney  and  suprarenal  capsule  are 
also  in  direct  apposition  with  the  posterior  surface  of  the  left 
part  of  the  body  of  the  pancreas.  The  inferior  surface  is 
bounded  below  by  the  fourth  part  of  the  duodenum  and  the 
beginning  of  the  jejunum.  The  head  of  the  pancreas  bends 
somewhat  downward  and  is  in  contact  behind  with  the  common 
bile  diict,  the  vena  cava,  the  left  renal  vein,  and  the  aorta.  In 
front  of  the  head  of  the  pancreas  are  found  the  superior  mes- 
enteric and  pancreatico-duodenal  ^'essels  and  the  transverse 
colon.  The  duct  of  the  pancreas  is  called  the  canal  of  Wir- 
sung,  and  runs  from  left  to  right  nearer  the  posterior  surface, 
turning  in  the  head  downward,  backward,  and  to  the  right 
to  meet  the  common  bile  duct.  With  the  latter  it  passes 
oblicjuely  through  into  the  duodenum,  though  occasionally  the 
canal  of  Wirsung  opens  by  itself  into  the  latter  part  of  the 
intestine.  There  is  also  usually  an  accessory  pancreatic  duct 
known  as  the  duct  of  Santorini,  which  opens  separately  into 
the  duodenum  about  one  inch  above  the  other  opening. 


LECTURE   II 

THE  NERVE  SUPPLY  OF  THE  DIGESTIVE 
ORGANS  AND  THE  RELATIONS  OF  THE 
SPINE  TO  THE  VASO-MOTOR  NERVES 

AccoRDiXG  to  ]\Iorris  ^  the  nen-es  supplying  the  stomach 
are  the  two  pneumogastrics  and  the  sympathetic.  The  right 
vagus  passes  over  the  posterior  surface  and  the  left  supplies 
the  anterior.  The  stomach  is  intimately  connected  with  the 
sympathetic  system  of  nerves  through  the' solar  plexus.  The 
nervous  supply  of  die  intestines  is  from  the  superior  mesenteric 
plexus  and  lower  part  of  the  solar  plexus.  The  branches 
follow  the  blood-vessels  forming  Auerbach's  and  Meissner's 
plexuses. 

The  anatomy  and  physiology  of  the  nervous  system  are  by 
no  means  yet  fully  worked  out  and  especially  with  regard  to 
the  vaso-motor  nerve  fibers  supplying  the  viscera  the  work  of 
investigation  is  still  going  on,  while  the  results  of  different 
physiologists  are  not  always  in  accord.  In  these  lectures  I 
shall  not  attempt  to  go  deeply  into  the  details  of  such  investiga- 
tions, quoting  the  views  of  the  dift'erent  authorities  and  the 
arguments  by  which  they  are  upheld,  but  shall  simply  give 
you  in  brief  the  facts  which  seem  fairly  well  established. 

Secretory  Nerves. — It  is  both  maintained  and  denied  that 
there  are  special  secretory  nerves  distributed  to  the  glandular 
structures,  but  Pawlow  and  his  pupils  "  seem  to  me  to  have 
finally  proved  beyond  cjuestion  that  there  are  in  the  vagi,  apart 

^  "  Human  Anatomy,"  by  Henry  Morris,  M.  A.  and  M.  B.,  P,  Blakiston's 
Son  &  Co.,  Philadelphia,  189S. 

'"The  AVork  of  the  Digestive  Glands,"  by  Professor  J.  P.  Pawlow, 
J.  B.  Lippincott  Company,  Philadelphia,  1902. 

47 


48       ANATOMIC,   PHYSIOLOGIC^  CHEMIC^  DIAGNOSTIC  DATA 

from  the  vaso-motor  fibers,  nerve  fibers  the  stimulation  of 
Avhich  produces  a  secretion  of  gastric  juice. 

It  had  long  before  been  accepted  as  a  settled  fact  that  the 
salivary  glands  at  least  are  supplied  with  a  special  secretory- 
nerve,  though  this  also  is  now  disputed  in  some  quarters.  Paw- 
low  brings  forward  results  of  experiments  which  tend  to  show 
that  there  are  probably  also  nerves  whose  particular  function 
it  is  to  inhibit  secretion.  Nature  displays  a  wonderful  plen- 
itude of  resources  and  whatever  structure  or  combination  of 
structures,  however  intricate,  can  aid  in  performing  any  func- 
tion, is  generally  supplied. 

The  Vaso-Motor  Nerves  and  the  Spine. — My  preceptor  in 
medicine,  the  late  Dr.  Matthew  J.  Grier,  was  accustomed 
in  the  seventies  to  apply  mild  galvanic  currents  through 
the  points  of  emergence  of  the  nerves  on  either  side  of 
the  spinal  column  with  one  electrode  stabile  over  the  stomach, 
and  in  this  way  produced  highly  favorable  results,  not  only 
upon  symptoms  referred  to  the  spine  itself  and  affections  of 
the  general  nervous  system,  but  also  in  many  cases  upon 
disease  in  the  parts  to  which  such  nerves  were  distributed. 
During  the  past  thirty-two  years  I  have  confirmed  the  value 
of  the  method  in  many  hundreds  of  cases. 

Professor  H.  C.  AVood  used  to  teach  the  usefulness  in  certain 
chronic  diseases  of  alternate  hot  and  cold  water  douches  to  the 
spine,  and  various  applications  of  heat  and  cold  to  the  spine 
are  in  common  use.  Move  recently  much  success  has  been 
claimed  for  various  methods  of  stimulating  the  spinal  nerves 
near  their  emergence  from  the  spine  by  mechanical  devices 
designed  to  produce  pressure  with  vibration  and  also  by  a 
species  of  massage  or  finger  pressure  over  these  parts,  con- 
tinuous or  intermittent  accordingly  as  contraction  or  dilation 
of  the  peripheral  vessels  may  be  desired.  Dr.  John  P.  Arnold 
in  particular  is  an  enthusiastic  advocate  of  this  latter  method.' 

The  clinical  successes  achieved  in  all  these  ways  are  con- 
firmatory of  the  conclusions  of  physiologists  that  vaso-motor 
'/«^.  Afed.  Ma£-.  for  May,  July^  and  August,  1903. 


NERVE    SUPPLY    OF    THE    DIGESTIVE    ORGANS  49 

nerve  fibers  pass  out  from  the  spinal  cord  with  the  spinal 
nerves  as  well  as  with  the  pneumogastrics  and  some  of  the 
other  cranial  nerves,  and  are  distributed  thence  to  the  periphery 
of  the  body  and  to  the  viscera. 

Those  nerves  which  control  the  caliber  of  the  arterioles 
include  the  vaso-constrictors,  stimulation  of  which  contracts 
the  vessels,  and  the  vaso-dilators,  which  have  an  opposite  effect. 
Both  of  these  .are  efferent  nerves  which  carry  impulses  outward 
to  their  peripheral  endings  from  the  vaso-motor  center  in  the 
medulla. 

Vaso-constrictors  and  vaso-dilators  pass  from  their  respect- 
ive portions  of  the  vaso-motor  center  down  through  the  ante- 
rolateral columns  of  the  spinal  cord  and  through  centers  in  the 
anterior  horns  of  the  latter  outward  to  join  the  anterior  bun- 
dles of  the  spinal  nerves,  thence  to  ganglia  of  the  sympathetic 
chain  of  nerves,  and  again  to  the  vessels  which  they  supply. 

There  are  also  other  vaso-motor  fibers  which  are  afferent 
or  ingoing  nerves  called  the  reflex  constrictors  and  reflex 
dilators.  Both  the  latter  convey  sensory  impressions  from  the 
periphery  of  the  body  or  the  viscera  to  certain  groups  of  cells 
in  the  ganglia  in  the  posterior  branches  of  the  spinal  nerves 
and  thence  into  the  cord  passing  upward  in  the  anterolateral 
columns  of  the  latter  to  the  vaso-motor  center  in  the  medulla, 
or  through  the  ganglia  of  the  cranial  nerves  more  directly  to 
the  same  center.  Excitation  of  the  peripheral  endings  of  the 
reflex  constrictors  or  reflex  dilators  produces  a  stimulation  of 
the  corresponding  part  of  the  vaso-motor  center  with  a 
resulting  contraction  or  dilatation  respectively  of  the  vessels  in 
the  peripheral  regions  from  which  such  nerves  take  their  ori- 
gin, whether  these  are  in-the  external  parts  or  the  viscera. 

The  afferent  vaso-motor  nerves  are  near  enough  the  surface, 
before  passing  into  the  spinal  cord,  to  be  influenced  by  heat  or 
cold,  pressure,  or  by  vibration  whether  produced  by  electricity 
or  special  mechanical  devices  when  applied  over  them  on  either 
side  of  the  cord. 

Course  and  Direction  of  the  Spinal  Nerves. — The  follow- 


50       ANATOMIC,   PHYSIOLOGIC^  CHEMIC^  DIAGNOSTIC  DATA 

ing,  quoted  from  Morris  ^  will  make  clearer  the  course  of  the 
spinal  nerves.  The  table  showing  the  distances  traveled  by  the 
nerves  (especially  the  lower  ones)  before  emerging  from 
the  spinal  column  will  be  of  especial  interest  and  practical 
value  to  those  of  you  who  treat  the  viscera  through  the 
spine : 

''  From  their  superficial  origin,  both  anterior  and  posterior 
roots  proceed  towards  the  intervertebral  foramina,  and  unite 
near  the  outer  limits  of  the  foramina  into  single  trunks.  The 
ganglia  on  the  posterior  roots  are  placed,  in  the  case  of  the 
majority  of  the  nerves,  within  the  foramina  immediately  inter- 
nal to  the  point  of  junction  of  the  two  roots.  The  ganglia  of 
the  first  and  second  cervical  nerves  are  placed  on  the  laminae 
of  the  atlas  and  axis.  The  ganglia  of  the  (first  and  second) 
sacral  and  coccygeal  nerves  are  placed  within  the  spinal  canal. 

"  The  roots  of  the  first  spinal  nerve  ascend  slightly  to  reach 
the  interval  between  the  atlas  and  the  occipital  bone. 

"  The  second  and  third  nerves  pass  horizontally  outwards, 
the  fourth  passes  obliquely  downwards  and  outwards,  and  the 
remaining  nerves  pass  out  with  increasing  degrees  of  obliquity, 
the  intraspinal  course  of  the  nerve-roots  increasing  in  length 
as  the  series  is  followed  downwards. 

"  It  follows  from  the  above  statement  that  the  lower  nerve- 
roots  are  directed  almost  vertically  downwards,  and  as  the 
spinal  cord  ends  at  the  level  of  the  second  lumbar  vertebra, 
while  the  series  of  intervertebral  foramina  is  continued  to  the 
lower  end  of  the  sacrum,  the  nerve-roots  passing  within  the 
vertebral  canal  beyond  the  cord  form  a  great  sheaf  of  fibers, 
the  Cauda  equina.  The  distance  of  the  points  of  emergence 
(superficial  origins)  of  certain  of  the  nerves  from  the  corre- 
sponding intervertebral  foramina  is  given  in  the  following 
table.  This  table  gives  the  measurements  made  by  Testut  in 
a  subject  of  eighteen  years.  The  length  of  the  spinal  cord  was 
in  this  case  forty-one  centimeters." 

'"  Human  Anatomy,"  Blakiston's  &  Co.,  Philadelphia,  i8q8. 


NERVE    SUPPLY    OF    THE    DIGESTIVE    ORGANS 


51 


Right  Side 

Left  Side 

mm. 

m.ra. 

Third  pair 

of  cervical  nerves 

18 

17 

Fifth 

... 

25 

25 

First 

'      thoracic      "               ... 

33 

32 

Fifth 

"             "               .        . 

47 

47 

Tenth 

"             "               .        . 

68 

68 

Twelfth    ' 

... 

III 

no 

First 

lumbar        " 

114 

114 

Second 

"             "               ,        . 

138 

134 

Third 

"             "               .        . 

151 

151 

Fourth      ' 

"             "               .        . 

163 

164 

Fifth 

"               .        . 

181 

180 

First 

sacral           "               .        . 

18S 

188 

Fifth 

.        . 

.     280 

280 

Remembering  that  a  millimeter  is  equal  to  one-twenty-fifth 
of  an  inch,  or  10  mm.  to  nearly  half  an  inch,  it  will  be  seen 
from  the  foregoing  table  that  the  fifth  cervical  nerves  leave  the 
spine  an  inch  below  their  origin  in  the  cord,  and  the  fifth  sacral 
nerves  eleven  inches  below  their  point  of  origin. 

Points  of  Emergence  from  the  Spine  of  Special  Vaso-Motor 
Nerves. — The  cerebral  blood-vessels  are  said  to  be  more  or  less 
under  the  control  of  vaso-motor  centers  in  the  spinal  cord 
chiefly  in  its  second  and  third  dorsal  segments.  Efferent  fibers 
pass  from  these  through  the  sympathetic  nerves  to  the  superior 
cervical  ganglion.  From  this  both  constrictor  and  dilator 
fibers  pass  along  the  internal  carotid  artery  to  the  vessels  in  the 
brain. 

Vaso-constrictor  nerve  fibers  for  the  salivary  glands  have 
their  origin  in  the  second  and  third  segments  of  the  thoracic 
part  of  the  spinal  cord,  enter  the  sympathetic  chain,  pass  on 
to  the  superior  cervical  ganglion,  and  thence  are  distributed 
to  the  parotid,  submaxillary,  and  lingual  glands.  Vaso-dilator 
fibers  for  the  parotid  gland  arise  in  the  nucleus  of  the  ninth 
cranial  nerve  and  accompany  the  latter,  passing  through  the 
jugular  foramen  to  the  otic  ganglion,  whence  they  proceed 
along  the  inferior  maxillary  branch  of  the  fifth  nerve  and  its 
auriculo-temporal  branches  to  the  gland. 

Vaso-dilator  fibers  originating  in  the  nucleus  of  the  seventh 


52        ANATOMIC,    PHYSIOLOGIC,   CHEMIC,  DIAGNOSTIC  DATA 

or  facial  nerve  follow  the  latter  and  thence  pass  through  the 
chorda  tympani  to  the  submaxillary  ganglion,  emerging  from 
the  cranium  through  the  stylo-mastoid  foramen.  From  the 
submaxillary  ganglion  dilator  fibers  are  distributed  to  the  sub- 
maxillary and  lingual  glands. 

Vaso-constrictor  fibers  for  the  stomach  emerge  from  the 
spine  with  the  fifth,  sixth,  seventh,  eighth,  and  ninth  dorsal 
nerves  through  the  intervertebral  foramina  and  pass  with  the 
visceral  nerves  to  the  semilunar  ganglion ;  thence  along  the 
blood-vessels  to  the  vessels  of  the  stomach  itself. 

Vaso-dilator  fibers  originate  in  the  nucleus  of  the  tenth  or 
pneumogastric  nerve  and  proceed  by  the  way  of  the  semilunar 
ganglion  to  the  gastric  blood-vessels. 

Vaso-constrictor  fibers  for  the  small  intestines  pass  from 
those  segments  of  the  spinal  cord  from  the  sixth  dorsal  to  the 
second  lumbar,  through  the  visceral  nerves  to  the  solar  plexus, 
and  thence  to  the  blood-vessels  of  the  duodenum,  jejunum,  and 
ileum. 

The  dilator  nerves  of  the  same  part  arise  in  the  nucleus  of 
the  pneumogastrics  and  go  to  the  solar  plexus.  Thence  they 
are  distributed  to  the  blood-vessels  of  the  small  intestines. 

The  vaso-motor  nerve  supply  of  the  liver  has  the  same  origin 
as  that  of  the  small  intestine,  and  that  of  the  pancreas  and 
spleen  varies  but  slightly  from  the  same. 

The  vaso-motor  mechanism  of  the  colon  has  in  part  the  same 
and  in  part  a  different  origin  from  that  of  the  small  intestines. 
The  constrictor  fibers  arise  in  the  same  part  of  the  cord — sixth 
dorsal  to  the  second  lumbar  segment — and  enter  the  inferior 
mesenteric  ganglion  before  their  distribution  to  the  blood-ves- 
sels of  the  various  portions  of  the  large  bowel. 

Dilator  fibers  for  the  colon  originate  in  the  same  segments  of 
the  cord  as  well  as  in  the  nucleus  of  the  pneumogastrics.  They 
pass  via  the  visceral  and  pneumogastric  nerves  to  the  solar  and 
inferior  mesenteric  ganglia,  and  thence  to  the  blood-vessels 
of  the  colon. 

The  sigmoid  flexure  and  rectum  receive  vaso-constrictor  nerve 


NERVE    SUPPLY    OF    THE    DIGESTIVE    ORGANS  53 

fibers  which,  arising  in  the  tenth  dorsal  to  the  fourth  lumbar 
nerve-roots,  pass  to  the  hypogastric  plexus,  and  thence  along 
the  hypogastric  nerves  to  the  vessels  of  the  parts.  The  dilator 
fibers  for  the  vessels  of  the  same  region  arise  much  lower 
dow^n,  in  the  first  to  the  fourth  sacral  segments  of  the  cord. 
They  proceed  then  to  the  corresponding  sacral  ganglia,  and 
thence  through  the  visceral  branches  of  the  sacral  nerves  to 
the  vessels  of  the  sigmoid  flexure  and  rectum. 

It  is  noteworthy  that  the  vaso-constrictors  for  the  sigmoid 
flexure  and  rectum,  and  also  those  for  the  principal  genital 
organs  of  both  sexes,  come  from  the  lumbar  nerve-roots,  while 
the  vaso-dilators  for  the  same  two  sets  of  organs  come  from 
the  sacral  plexus.  This  accounts  for  the  often  observed  inti- 
mate sympathy  between  the  lower  bowel  and  the  sexual  appa- 
ratus.   Whenever  one  is  disturbed  the  other  is  rarely  normal. 


LECTURE  III 

THE  PHYSIOLOGY   OF  DIGESTION,  AB- 
SORPTION,   AND    DEFECATION 

Salivary  Digestion. — Digestion  begins  in  the  mouth  with 
mastication  and  insahvation.  These  two  processes  are  among 
the  most  important  of  those  which  prepare  the  food  for  assimi- 
lation. Their  importance  is  little  miderstood  by  the  laity,  and 
by  no  means  sufficiently  emphasized  by  writers  upon  diseases 
of  the  gastro-intestinal  tract.  Physicians  do  not  always  pay 
sufficient  heed  to  them  in  their  directions  to  patients  concern- 
ing diet,  etc.  Man  in  his  primitive  condition  was  obliged  to 
chew  his  food  with  unusual  thoroughness  because  it  was 
crude,  coarse,  very  often  tough  and  uncooked.  With  ad- 
vancing civilization  our  cooks  have  been  constantly  endeavor- 
ing to  lessen  and  lighten  the  work  of  the  muscles  of  mastication 
and  salivary  glands,  thereby  increasing  the  labor  of  the  stomach 
and  intestinal  glands  and  multiplying  digestive  maladies. 
Nature  has  so  arranged  matters  that  the  act  of  mastication 
promotes  the  secretion  of  the  salivary  glands  and  possibly  also 
that  of  the  gastric,  pancreatic,  and  intestinal  glands  by  a  reflex 
influence.  The  function  of  the  salivary  glands — the  parotid, 
submaxillary,  and  sublingual — is  to  secrete  the  saliva.  The 
latter  is  a  thin  liquid  of  alkaline  reaction  of  the  sp.  gr.  of  1,002- 
1,009.  The  quantity  secreted  in  twenty-four  hours  is  from  2 
to  4  pints  (946  to  1892  c.  c.)  ;  Bidder  and  Schmidt  say  1400 
to  1500  c.  c.  The  saliva  contains  a  diastatic  enzyme  called 
ptyalin,  which  has  the  property  of  changing  starch  into  a  form 
of  sugar,  maltose,  with  usually  a  small  amount  of  grape 
sugar.  This  conversion  begins  in  the  mouth  during  the  act  of 
chewing,  and  the  longer  the  latter  is  continued  the  more  com- 

54 


PHYSIOLOGY    OF    DIGESTION^    ABSORPTION^    DEFECATION        55 

pletely  is  it  effected.  Usually,  the  process  is  merely  com- 
menced in  the  mouth,  and  when  the  gastric  contents  are  not 
too  highly  acid,  is  carried  further  forward  after  the  food 
reaches  the  stomach.  Under  normal  conditions,  when  the 
percentage  of  HCl  in  the  gastric  juice  is  not  too  high,  this 
salivary  digestion  or  starch  conversion  goes  on  in  the  stomach 
for  some  thirty  minutes  or  more  when,  under  even  the  most 
favorable  conditions,  it  is  commonly  terminated  by  the  increas- 
ing acidity  of  the  stomach  contents.  When  the  latter  are 
exceedingly  acid,  as  in  marked  cases  of  hyperchlorhydria,  sali- 
vary digestion  may  be  checked  at  once,  and  the  conversion  of 
the  starch  into  maltose  cannot  then  be  completed  until  the  con- 
tents of  the  stomach  are  passed  on  into  the  intestines,  when 
normally  the  pancreatic  juice,  aided  by  the  bile  and  intestinal 
juice,  complete  the  process.  However,  when  there  is  present 
in  the  stomach  a  marked  excess  of  HCl,  the  pyloric  outlet 
remains  closed  much  longer  than  normal  and  the  unconverted 
starch  is  subjected  to  the  danger  of  fermentation  for  an  excep- 
tionally long  period.  Aggravated  flatulency  then  results. 
Boas  gives  the  following  proportions  of  HCl  and  other  acids  as 
effective  in  checking  or  stopping  entirely  salivary  digestion 
in  the  stomach : 

Checked  by  Stopped  by 

Hydrochloric  acid 07  per  cent.  .12  per  cent. 

Lactic  acid  i      "       "  .15    "       " 

^"ty"^ "  i 2  -    "    .4to 

Acetic     "    ) 


•5 


The  saliva  serves  other  useful  purposes  in  softening  or  pul- 
pefying  and  lubricating  the  food,  dissolving  the  salts  in  it, 
and  imparting  to  it  an  alkaline  reaction.  The  saliva,  upon 
reaching  the  stomach,  also  stimulates  the  secretion  of  the  gas- 
tric juice. 

Gastric  Digestion  is  performed  by  the  gastric  juice,  an  acid 
liquid  of  the  sp.  gr.  of  1,002-1,003.  It  contains  HCl,  pepsin, 
and  rennin  (the  milk-curdling  ferment),  and,  as  has  been 
recently  demonstrated,  a  small  quantity  of  a  substance  which 


56       ANATOMIC,    PHYSIOLOGIC^   CHEMIC^  DIAGNOSTIC  DATA 

has  the  property,  to  some  extent,  of  emulsifying  fats.  No  reli- 
able data  are  at  hand  as  to  the  total  quantity  of  gastric  juice 
secreted,  but  Griinewald  estimated  it  at  1580  c.  c,  that  is, 
about  three  pints.  The  normal  percentage  of  HCl  in  the  gastric 
juice  has  been  variously  estimated,  but  may  be  accepted  as 
approximately  o.  i  to  0.2.  At  the  height  of  the  digestion  of  a 
light  breakfast,  such  as  the  test  breakfast  originally  prescribed 
by  Ewald,  a  little  more  than  one-half  of  the  HCl  present 
should  be  in  the  free  form  and  somewhat  less  than  half  com- 
bined with  the  proteid  food.  The  HCl  of  the  gastric  juice 
has  a  decided  antiseptic  action  for  many  bacteria,  but,  as  should 
be  carefully  borne  in  mind,  does  not  interfere  at  all  with  the 
development  of  the  yeast  germ,  which  is  responsible  for  a  large 
share  of  the  usual  gastric  fermentation.  Gastric  enzymes  exist 
primarily  in  the  forms  of  pepsinogen  and  rennin  zymogen, 
which  in  the  presence  of  HCl  are  changed  respectively  into  the 
active  forms  of  pepsin  and  rennin.  Pepsin,  in  the  presence  of 
sufficient  free  HCl,  converts  proteid  or  albuminoid  food  ele- 
ments into  the  more  soluble  propeptones  and  peptones.  Gelatin 
is  also  changed  by  this  compound  into  gelatin-peptone,  and 
elastine  into  elastine-peptone.  Other  mineral  acids  can  be 
substituted  for  HCl  and  will  enable  the  pepsin  to  effect  the 
same  changes,  but  much  less  efficiently;  and  in  a  still  lower 
degree,  lactic,  acetic,  and  butyric  acids  are  also  capable  of 
substituting  the  HCl.  The  rennin  zymogen  is  the  most  con- 
stant constituent  of  the  gastric  juice,  and  in  conditions  of 
disease  has  been  found  to  persist  generally  even  after  the 
entire  disappearance  of  HCl  and  pepsin. 

The  property  of  rennin  is  to  produce  a  light  flaky  coagula- 
tion of  milk.  It  should  not  be  forgotten  in  this  connection 
that  a  denser  coagulation  may  be  produced  in  milk  by  HCl 
alone. 

The  motor  function  of  the  stomach  is  of  the  greatest  assist- 
ance to  the  action  of  the  gastric  juice.  The  churning  move- 
ments keep  the  contents  in  constant  motion,  and  mix  the  gas- 
tric juice  through  all  parts  of  the  mass,  bringing  it  into  con- 


PHYSIOLOGY    OF    DIGESTION,    ABSORPTION,    DEFECATION        5/ 

tact  with  every  portion  of  it,  while  the  propulsive  movements 
empty  the  stomach.  The  pylorus  normally  opens  rhythmically 
every  few  minutes  during  digestion,  and  the  more  liquid  con- 
tents are  then  expelled  by  contractions  of  the  muscles  of  the 
antrum  pylori.  With  lowered  gastric  motility  digestion  does 
not  go  on  efficiently,  even  with  a  normal  or  excessive  secretion 
of  the  HCl  and  pepsin:  Indeed,  an  excess  of  HCl  usually  tends 
to  a  lessened  peptone  production.  On  the  other  hand,  there 
may  be  a  complete  absence  of  secretion  without  serious  dis- 
turbance of  nutrition  or  great  inconvenience  to  the  patient, 
provided  the  gastric  motility  is  w^ell  maintained,  so  that  the 
stomach  contents  are  promptly  propelled  into  the  duodenum, 
where  the  other  digestive  juices  can  have  access  to  them. 

It  is  noteworthy  in  this  connection  that  an  excessive  secre- 
tion of  HCl,  which  often  causes  a  prolonged  spasmodic  closure 
of  the  pylorus  with  long-delayed  emptying  of  the  stomach,  pro- 
duces usually  more  serious  symptoms,  more  distress  to  the 
patient  in  the  beginning,  and  a  greater  number  of  important 
sequels  in  the  end,  than  does  a  deficiency  of  the  same  secretion, 
provided  always  the  latter  fault  is  compensated  for  by  an 
active  gastric  motor  power  and  functionally  efficient  intestinal 
digestion.  Experiments  performed  in  Pawlow's  laboratory 
indicate  that  the  closure  of  the  pylorus  is  determined  by  the 
reaction  of  the  contents  of  the  duodenum.  When  these  are 
rendered  acid  by  excessive  acidity  of  the  chyme,  the  pylorus 
closes  by  reflex  action.  When  the  duodenal  contents  again  be- 
come neutral  or  alkaline,  the  pylorus  opens  to  admit  a  fresh 
portion  of  chyme. 

Intestinal  digestion,  in  so  far  as  is  yet  definitely  known,  is 
comprised  in  the  action  of  the  pancreatic  juice,  the  bile,  and  the 
succus  entericus  or  intestinal  juice.  The  pancreatic  juice  is 
secreted  by  the  pancreas  and  finds  its  way  into  the  duodenum 
through  the  duct  of  Wirsung;  the  bile  secreted  by  the  liver  and 
stored  up  in  the  gall-ljladder  flows  through  the  cystic  and  com- 
mon bile  ducts  and  enters  the  duodenum  commonly  through 
the  same  opening  as  the  pancreatic  juice.     Some  recent  inves- 


58       ANATOMIC,    PHYSIOLOGIC^   CHEMIC^  DIAGNOSTIC  DATA 

tigators  ha\'e  reported  evidences  that  an  internal  secretion  of 
the  spleen  assists  the  action  of  the  pancreatic  juice,  probably 
by  converting  the  trypsin  zymogen  into  the  active  proteolytic 
ferment  called  trypsin.  All  of  the  three  digestive  juices  above 
described,  which  meet  and  perform  their  functions  in  the  in- 
testine^  are  more  or  less  alkaline  and  gradually  neutralize  the 
acidity  of  the  gastric  juice.  They  are  active  in  an  alkaline, 
neutral,  or  slightly  acid  medium,  but  not  in  a  highly  acid  one. 
Free  HCl,  even  in  small  proportion,  has  been  shown  to 
inhibit  pancreatic  digestion.  This  helps  to  explain  the  injuri- 
ous results  to  nutrition  of  an  excessive  secretion  of  HCl.  All 
of  these  three  secretions  likewise  have  some  fat-emulsifying 
power;  this  work  is  done  chiefly  by  the  pancreatic  and  intes- 
tinal juices,  but  goes  on  much  more  rapidly  in  the  presence  of 
bile.  The  secretion  of  the  pancreatic  juice  in  man  is  now 
believed  to  be  continuous  to  some  extent,  accumulating  in  the 
excretory  ducts  of  the  pancreas  between  the  digestive  periods 
a  small  amount,  but  being  secreted  much  more  abundantly 
during  digestion.  Various  kinds  of  stimuli,  mechanical  and 
chemical,  are  efficient  in  exciting  the  secretion  of  this  juice, 
but  the  chief  one  is  the  presence  of  an  acid  chyme  in  the  duo- 
denum. The  amount  of  the  daily  secretion  of  the  pancreatic 
juice  has  never  been  accurately  determined.  It  is  the  most 
active  of  all  the  digestive  secretions.  It  combines  the  proper- 
ties of  both  the  saliva  and  gastric  juice,  having  the  power  of 
converting  starch  into  sugar  or  completing  that  process  when 
partly  effected  in  the  stomach,  and  also  has  a  greater  proteo- 
lytic or  albumin-digesting  power  than  the  gastric  juice,  besides 
tlie  ability  to  emulsify  fats  and  produce  changes  in  milk 
analagous  to,  but  not  identical  with,  its  coagulation  by  rennin. 

The  bile,  a  yellow  or  brownish  liquid,  is  a  continuous  secre- 
tion from  the  cells  of  the  liver.  It  is  alkaline,  and  the  quan- 
tity formed  daily  has  been  estimated  at  from  i  to  2^  pints 
(473  to  1 182  c.  c).  Bile  is  to  be  considered  as  an  excretion 
as  well  as  a  secretion.  It  contributes  somewhat  to  the  proc- 
esses of  intestinal  digestion,  being  a  stimulant  to  the  peristaltic 


PHYSIOLOGY    OF    DIGESTION^    ABSORPTION,    DEFECATION        59 

apparatus,  and  assists  in  maintaining  the  normal  bowel  func- 
tions besides  aiding  in  the  splitting  up  of  the  fats  by  forming 
soaps  with  the  solid  neutral  ones.  Antiseptic  properties  have 
been  claimed  for  the  bile,  and  though  this  claim  has  been  dis- 
puted, it  probably  lessens  somewhat  the  activity  of  certain  of 
the  intestinal  bacteria.  Bile  also  assists  in  the  assimilation  and 
absorption  of  fats. 

Besides  secreting  the  bile,  the  liver  possesses  other  vitally 
important  functions  in  the  normal  metabolism  or  tissue 
changes,  including  the  destruction  of  poisonous  substances 
introduced  into  the  digestive  system  from  without  or  formed 
within  the  body.  All  the  blood  from  the  digestive  organs  must 
pass  through  the  portal  vein  and  be  brought  into  contact  with 
the  hepatic  cells  before  passing  on  to  the  heart.  According 
to  the  theory  of  auto-intoxication,  now  sufficiently  well  estab- 
lished, the  liver  is  the  great  defender  of  the  system  against  the 
numerous  poisons  constantly  formed  during  the  metabolic 
processes.  Urea  is  now  known  to  be  produced  largely,  if  not 
chiefly,  in  the  liver.  Moreover,  glycogen  is  formed  in  the  same 
gland  from  the  digested  carbohydrates  as  well  as  from  pro- 
teid  food,  and  is  stored  up  there  to  be  reconverted  into  sugar 
and  then  distributed  to  the  system  as  needed.  This  peculiar 
function  is  believed  to  be  possessed  to  some  extent  also  by  the 
muscles  and  perhaps  other  tissues. 

Absorption. — Pure  water  is  scarcely  absorbed  at  all  from  the 
stomach,  but  diluted  alcohol  is  freely  absorbed,  as  are  also 
solutions  of  the  sugars  when  in  a  concentration  of  5  per  cent, 
or  higher.  Peptones  are  only  slowly  and  with  difficulty  ab- 
sorbed by  the  stomach.  In  the  small  intestine  all  the  soluble 
products  of  digestion,  peptones,  sugars,  and  emulsified  fats 
are  readily  and  rapidly  absorbed  through  the  medium  of  the 
lacteals  of  the  lymphatic  system  and  in  part  directly  into  the 
blood.  In  the  large  intestine  absorption  is  much  less  active 
and  proceeds  more  slowly,  but  still  takes  place  to  a  considerable 
extent.  Hence  the  loss  to  the  system  of  a  too  prolonged  em- 
ployment of  colonic  irrigation. 


60       ANATOMIC,   PHYSIOLOGIC^  CHEMIC^  DIAGNOSTIC  DATA 

Absorption  in  the  intestine  takes  place  chiefly  through  the 
vilH  and  the  soHtary  glands.  The  former  are  limited  to  the 
small  intestine,  none  of  them  being  found  in  any  part  of  the 
colon.  The  solitary  glands  are  most  numerous  in  the  ileum, 
but  rqany  of  them  are  also  irregularly  scattered  throughout 
the  various  parts  of  the  large  intestine.  '  Pohlman  infers 
from  the  limited  number  of  any  specialized  organs  for  ab- 
sorption in  the  colon,  and  particularly  in  view  of  its  well-known 
absorbing  power,  that  its  whole  mucous  membrane  has  the 
power  of  absorption,  as  is  the  case  with  that  of  the  stomach  for 
a  limited  number  of  substances.  The  villi  and  solitary  glands 
are  thus  tersely  described  by  Pohlman  •} 

"  The  villi,  little  cone-shaped  protuberances  in  the  mucous 
membrane,  have  a  dense  network  of  blood  capillaries  just 
underneath  their  epithelial  covering,  while  a  lacteal  duct 
occupies  the  center  of  the  cone.  The  solitary  glands  have  a 
dense  lacteal  plexus  beneath  the  membrane  and  a  limited 
supply  of  blood  capillaries.  All  the  blood  capillaries  of  the 
intestinal  tract  are  radicles  of  the  portal  vein,  while  the  lacteal 
ducts  and  capillaries  are  radicles  of  the  abdominal  lymphatics. 
The  villi,  however,  are  the  principal  organs  and  carry  the  bulk 
of  the  peptones  and  sugars  into  the  circulation  directly,  while 
the  emulsified  fats  absorbed  are  poured  by  the  way  of  the 
lacteals  and  abdominal  lymphatics  into  the  receptaculum  chyli, 
and  from  there  through  the  thoracic  duct  into  the  left  sub- 
clavian vein." 

Everything  ingested,  excepting  fats  and  water,  must  pass 
through  the  liver  before  it  can  be  taken  up  for  the  uses  of  the 
body.  Only  a  small  amount  of  the  fats  are  broken  up  into 
fatty  acids  and  glycerin,  the  chief  part  of  such  food  ingested 
being  first  emulsified  and  absorbed  in  that  form.  The  large 
intestine  is  able  to  absorb  not  only  digested  foods,  but  also  to 
some  extent  undigested  nutriments  such  as  solutions  of 
albumin,  etc.     Hence  the  utility  of  nutritive  enemas. 

1  Article  on  Absorption,  Wood's  "Reference  Hand-Book,"  vol.  i.,  New 
York,  I  goo. 


PHYSIOLOGY   OF   DIGESTION^   ABSORPTION^   DEFECATION       6l 

Defecation. — The  feces  are  what  remain  of  the  food  and 
drink  after  aU  has  been  absorbed  that  should  be.  The  process 
of  absorption  having  gone  on  continuously,  the  ingesta,  which 
are  fluid  throughout  the  whole  course  of  the  small  intestines, 
gradually  assume  the  solid  form  as  they  pass  through  the 
cecum  and  colon  until  by  the  time  they  have  reached  the 
sigmoid  flexure  they  should  be  in  the  form  of  a  putty-like  semi- 
solid mass,  and  in  passing  through  the  rectum  they  normally 
become  molded  into  the  sausage  form.  In  conditions  of 
health  there  is  usually  a  movement  of  the  bowels — that  is  a 
discharge  of  feces  from  the  rectum — once  in  twenty-four 
hours,  although  there  may  be  two  or  three  in  the  twenty-four 
hours,  or  one  only  in  each  two  or  three  days  in  conditions 
which  seem  to  approximate  those  of  health.  When  the  bowel 
movement  occurs,  as  is  most  usual,  in  the  morning,  the  feces 
accumulate  during  the  night  in  the  descending  colon  and  are 
arrested  in  the  sigmoid  flexure  by  the  superior  sphincter  of  the 
rectum.  When  the  accumulation  is  sufficient  to  make  the  act 
of  defecation  necessary,  the  pressure  upon  the  superior  sphinc- 
ter causes  the  latter  to  yield  and  a  portion  of  the  feces  enter 
the  rectum.  If  this  warning  is  unheeded  the  fecal  matter 
returns  to  the  sigmoid  flexure,  and  this  process  may  be  re- 
peated several  times  before  the  pressure  becomes  so  urgent 
that  it  can  no  longer  be  resisted.  In  some  cases,  however, 
when  the  peristaltic  action  is  less  vigorous  than  usual,  the 
repeated  calls  to  stool  may  be  disregarded  and  the  rectum  thus 
become  tolerant  of  the  accumulation  of  feces.  Thus  the  rec- 
tum is  gradually  overdistended  and  weakened  until  a  very 
obstinate  form  of  constipation  results.  In  the  lower  part  of 
the  rectum  there  is  an  internal  sphincter  in  addition  to  the 
external  sphincter  at  the  anal  orifice.  The  muscle  forming  the 
inner  sphincter  is  an  involuntary  one,  while  the  external 
sphincter,  composed  of  striated  muscular  fibers,  is  to  a  large 
extent  under  the  control  of  the  will,  though  it  may  relax  in 
spite  of  the  will  if  the  pressure  upon  it  is  exceedingly  great. 
The  innervation  of  the  colon  is  in  part  from  the  sympathetic 


62       ANATOMIC,    PHYSIOLOGIC^   CHEMIC^  DIAGNOSTIC  DATA 

and  in  part  from  the  lower  spinal  nerves.  The  vaso-constrictor 
nerve  fibers,  as  already  described,  rise  from  that  part  of  the 
cord  between  the  sixth  dorsal  and  the  second  lumbar  segment. 
The  v^.so-dilator  fibers  of  the  colon  rise  from  the  same  part 
of  the  spinal  cord  and  from  the  pneumogastrics.  The  vaso- 
constrictor nerves  supplying  the  sigmoid  flexure  and  rectum 
come  from  the  tenth  dorsal  to  the  fourth  lumbar  segments  of 
the  cord,  while  the  vaso-dilators  for  the  same  parts  originate 
between  the  first  and  fourth  sacral  segments  of  the  cord.  Both 
motor  and  inhibitory  nerve  fibers  supply  the  muscles  of  the 
rectum,  some  coming  from  the  lumbar  plexuses  and  others 
from  the  interior  mesenteric  and  hypogastric  plexuses  of  the 
sympathetic  system.  What  has  been  called  the  defecation 
center  is  now  usually  located  in  the  second  segment  of  the 
lumbar  part  of  the  cord.  There  is  also  known  to  be  a  nervous 
connection  between  the  cerebral  centers  and  the  muscles  of  the 
rectum. 

Interference  with  normal  defecation  may  arise  from  either 
atony  of  the  peristaltic  muscular  apparatus  leading  to  a 
deficiency  of  expulsive  force,  or  from  irregular  spasmodic  con- 
tractions of  the  circular  muscular  fibers  producing  what  is  now 
known  as  spastic  constipation ;  also  from  displacements  of  the 
intestines  or  neighboring  viscera,  tumors,  etc.^  This  subject 
is  discussed  at  length  under  the  head  of  Constipation  and  also 
in  Lecture  LXIV.  on  Intestinal  Obstruction. 

1  Adhesions  of  parts  of  the  bowel  to  other  parts  after  surgical  operations 
or  attacks  of  inflammation,  are  other  causes  of  constipation. 


PART    II 
METHODS   OF   EXAMINATION 


LECTURE  IV 
THE    INTERROGATION    OF  THE    PATIENT 

Importance  of  a  Full  History. — It  is  always  advisable,  when 
practicable,  to  obtain  from  patients  detailed-  accounts  of  their 
past  and  present  symptoms,  with  the  chief  facts  in  the  family 
history.  Indeed,  this  is  often  a  very  necessary  preliminary, 
if  you  are  to  make  such  an  examination  as  shall  lead  you  to  a 
correct  diagnosis  in  any  very  obscure  or  chronic  case  of  ill 
health. 

Though  this  series  of  lectures  deals  predominantly  with 
diseases  and  derangements  of  the  organs  concerned  in  the 
processes  of  digestion,  you  cannot  be  expected  to  know  in 
advance  that  any  individual  case  which  claims  your  attention 
is  a  stomach  or  intestinal  case.  The  fact  that  the  patient 
thinks  so  by  no  means  proves  it.  The  real  lesion  may  be  else- 
where, and,  even  with  the  fullest  possible  history  obtainable 
from  the  patient,  you  may  sometimes  be  misled.  You  may  be 
induced  thereby  to  examine  exhaustively  the  entire  digestive 
tract,  carrying  out  the  tests  of  the  gastric  juice,  feces,  etc., 
without  finding  there  the  origin  of  the  trouble,  its  seat  being 
elsewhere ;  but  you  are  much  less  likely  thus  to  waste  your 
time  and  put  the  patient  to  unnecessary  expense,  if  you 
institute  the  most  searching  inquiries  beforehand  concerning 
all  the  functions  and  systems  of  the  body. 

Naturally  the  exigencies  of  a  large  practice  will  render  it 
impracticable  to  examine  minutely  every  part  of  every  patient's 
body,  to  say  nothing  of  analyses  of  the  secretions  and  excre- 
tions and  thorough  examinations  of  the  blood.  But  whenever 
a  patient  has  long  complained  of  symptoms  which,  being  only 
temporarily  relieved  by  remedies,  point  to  some  chronic  lesion 

65 


66  METHODS    OF    EXAMINATION 

or  derangement  in  any  part  of  the  system,  it  is  necessary  to 
make  a  full  and  careful  incjuiry  into  his  condition  and 
antecedents.  Let  us  suppose  he  complains  of  constipation, 
headache,  and  nervousness  with  insomnia — a  very  frequent 
combination — and  that  no  permanent  relief  has  been  afforded 
by  cholagogues,  laxatives,  sedatives,  or  hypnotics.  Indeed, 
the  hypnotics  not  only  generally  fail  to  do  more  than  palliate 
temporarily,  but  often  finally  aggravate  such  cases.  You  may 
think  of  a  possible  brain  lesion,  such  as  a  chronic  meningitis, 
cerebral  tumor  (gumma),  etc.,  but  should  also  suspect  a 
toxsemic  neurasthenia  or  arteriosclerosis  resulting  from  a 
faulty  diet  and  too  little  physical  exercise,  with  probably 
excessive  mental  work,  worry,  dissipation,  or  sexual  irregu- 
larities. When  the  patient  is  at  or  beyond  middle  age, 
arteriosclerosis  will  be  the  most  probable  cause,  especially  if 
the  superficial  arteries  are  hardened  or  tortuous. 

In  the  case  stated,  the  family  history  will  tell  you  whether 
or  not  there  is  a  tendency  to  gastro-intestinal  disorders,  for 
such  a  tendency  is  notoriously  likely  to  be  inherited,  or  whether 
the  patient's  forebears  have  had  specially  vulnerable  nervous 
systems.  The  personal  history,  if  fully  elicited  by  skillful 
questioning,  may  reveal  at  least  a  suspicion  of  syphilis  or 
tuberculosis,  which  would  direct  your  inquiries  and  examina- 
tions particularly  toward  the  brain,  though  even  such  a  history 
would  not  exclude  neurasthenia  of  autotoxsemic  origin  as  the 
active  cause  of  the  trouble. 

The  less  dexterous  and  expert  a  physician  is  in  the  technical 
arts  which  are  indispensable  to  a  good  diagnostician,  and  the 
more  deficient  his  training  in,  or  facilities  for,  thorough  labora- 
tory work,  the  greater  the  help  he  may  derive  from  an 
unusually  full  and  minute  account  of  the  history  and  symp- 
tomatology of  any  case.  The  gastro-enterologist  should  be  able 
usually  to  diagnosticate  a  well-marked  type  of  gastric  ulcer 
or  acid  gastric  catarrh,  for  example,  after  making  a  physical 
examination  and  testing  the  stomach  contents,  even  without 
having  heard  a  word  of  the  family  or  personal  history  or 


THE    INTERROGATION    OF    THE    PATIENT  (>y 

symptoms;  yet  most  specialists  regularly  obtain  and  record  a 
full  history,  and  you  would  do  well,  in  doubtful  cases  at  least 
(in  new  cases  especially),  to  get  all  the  help  possible  from  the 
same  source.  Besides  the  name,  age,  residence,  and  occupa- 
tion, ask  the  present  weight  of  the  patient,  the  best  former 
weight,  and  how  long  a  time  the  loss  or  gain  has  been  going 
on.  Inquire  as  to  the  health  of  the  parents,  or,  if  dead,  the 
age  and  cause;  also  as  to  the  health  of  brothers  and  sisters. 
Ask  when  the  patient  first  began  to  be  out  of  health  and  about 
previous  acute  illnesses.  Note  down  systematically  all  the 
salient  medical  facts  with  which  the  patient  is  able  to  acquaint 
you,  recording  particularly  the  answers  given  regarding  the 
state  of  the  chief  functions  and  the  persistent  or  frequently  re- 
curring symptoms,  before  proceeding  to  make  your  examina- 
tion. 

The  patient  usually  has  his  own  theory  as  to  the  proper 
diagnosis,  and  will  often  try,  though  perhaps  unconsciously,  to 
impose  this  upon  you  by  magnifying  or  emphasizing  such 
symptoms  as  seem  to  bear  it  out,  and  minimizing,  or  even 
neglecting  altogether,  any  mention  of  those  referring  to  organs 
or  functions  which  he  deems  healthy.  Keeping  your  own 
mind  as  free  as  possible,  therefore,  from  bias,  you  should  make 
inquiries  as  to  all  the  leading  functions  before  deciding  upon 
the  diagnosis.  A  good  rule  to  follow,  in  important  cases,  is 
to  begin  at  the  head  and  ask  questions  likely  to  elicit  informa- 
tion regarding  the  condition  and  activities  of  the  various  parts 
in  a  certain  order,  beginning  with  the  brain  and  spinal  cord, 
then  inquiring  about  the  upper  respiratory  tract,  lungs,  etc., 
the  heart  and  circulation,  the  digestive  system,  and  the 
genito-urinary  apparatus. 

Systematic  Questioning. — Taking  these  up  in  order,  you 
should  inquire  as  to  the  memory  and  capacity  for  sustained 
mental  effort ;  as  to  the  sleep,  whether  sound  and  ample,  or  in 
any  way  imperfect,  and  if  so  in  what  way;  as  to  any  tendency 
to  headaches,  and  if  so,  whether  they  always  follow  some 
special  provocation,  such  as  imprudence  in  eating  or  drinking, 


68  METHODS    OF    EXAMINATION 

overfatigue,  etc.,  or  recur  at  intervals,  as  in  migraine,  without 
any  apparent  exciting  cause ;  further  as  to  backache,  numbness 
or  tinghng  in  the  extremities,  etc. 

Next  you  should  inquire  as  to  any  history  or  present 
existence  of  catarrh  in  the  upper  respiratory  passages,  cough, 
asthma,  former  attacks  of  influenza,  pneumonia,  pleurisy,  or 
bronchitis. 

Coming  to  the  circulatory  system,  you  should  ask  whether 
there  is,  or  has  been,  palpitation  of  the  heart,  pain  in  the  pre- 
cordia,  shortness  of  breath  on  exertion,  cold  extremities, 
oedema  of  the  feet  or  ankles,  etc. 

The  digestive  system  requires  particular  attention,  since 
derangements  here  are  more  common  than  those  of  any  other 
functions,  and  may  affect  directly  or  indirectly  all  the  other 
systems.  You  should  inquire  concerning  the  appetite  for  each 
of  the  three  usual  meals,  whether  abnormally  great,  slight  at 
first  but  increased  somewhat  after  beginning  to  eat,  or  absent, 
with  or  without  a  disgust  or  loathing  for  food;  any  peculiar 
taste  in  the  mouth  mornings ;  whether  there  is  unusual  thirst 
or  lack  of  it,  the  number  and  character  of  meals  taken  daily,  as 
well  as  the  hours  of  the  day  when  they  are  eaten,  how  punct- 
ually they  are  taken  then,  and  the  time  usually  spent  in  eating 
them — which  is  often  a  better  way  to  put  the  question  than  to 
ask  bluntly  whether  the  patient  eats  slowly,  with  thorough 
chewing,  or  fast  with  incomplete  mastication.  Another  in- 
direct method  of  learning  whether  or  not  there  is  poor  mastica- 
tion, perhaps  the  most  frecpent  cause  of  indigestion,  is  to 
inquire  whether  much  fluid  is  taken  with  meals,  and,  if  so, 
whether  it  is  used  to  help  wash  down  the  food  or  only  after 
the  boluses  of  the  latter  liave  been  swallowed.  It  is  well,  too, 
that  the  patient  should  be  asked  about  the  condition  of  the 
gums  and  teeth,  and  the  ability  of  the  latter  to  do  the  work 
required  of  them. 

How  to  Detect  Dietetic  Sins. — All  methods  of  finding  out  a 
patient's  pet  dietetic  sins  will  now  and  then  fail,  but  one  of 
the  surest  (with  the  exception  of  resorting  to  frequent  lavage) 


THE    IXTERROGATIOX    OF    THE    PATIENT  69 

is  to  get  him  to  jot  down  regularly  what  is  eaten  or  drunk  at 
each  meal  as  well  as  the  tidbits  and  the  extra  lunches  between 
meals  at  teas,  receptions,  etc. — both  the  various  articles  and  the 
amounts  of  each  ingested.  There  are  dyspeptics  who,  though 
they  have  (as  the  Germans  say  all  persons  have)  the  stomachs 
they  deserve  to  have,  will  tell  pretty  nearly  the  truth,  when 
obliged  to  put  down  the  facts  thus  in  black  and  white.  This 
method  is  practicable  after  treatment  has  been  regularly  begun, 
but  in  recording  the  history  at  the  outset,  you  will  of  course 
have  to  depend  largely  upon  the  usualh^  rather  vague  general 
answers  to  your  questions  as  to  what  is  commonly  eaten. 
However,  by  asking  specifically,  for  example,  at  how  many 
meals  meat  is  eaten  each  day,  the  kind  and  how  cooked,  as  well 
as  what  desserts,  what  beverages, — if  alcoholic  ones,  the  kinds 
and  quantities,  and  if  coffee  or  tea,  how  much  and  how  strong, 
— you  can  generally  get  some  idea  as  to  the  prevailing  habit  or 
tendencies  of  the  patient  regarding  diet. 

Pain  or  Discomfort. — You  should  incjuire  particularly  con- 
cerning any  discomfort  or  pain  during  or  after  meals,  whether 
in  the  esophagus,  gastric  region,  or  elsewhere  in  the  abdomen. 
If  difficulty  in  swallowing  is  complained  of,  ask  as  to  its  exact 
location  and  degree  of  persistency,  or  if  occasional  only,  the 
times  of  recurrence,  and  whether  the  food  sometimes  comes 
up  again  (regurgitation)  on  account  of  it;  also  whether  liquid 
readily  passes  into  the  stomach  even  when  solids  do  not.  If 
pain  occurs,  ask  whether  before  or  after  eating,  and  if  after, 
ascertain  exactly  to  what  part  of  the  epigastrium  it  is  referred 
and  if  felt  also  in  the  back,  how  long  after  and  whether  after 
all  meals  as  a  rule,  or  after  large  ones  orly,  or  after  particular 
kinds  of  food,  or  apparently  regardless  both  of  the  amount  and 
the  quality  of  food  or  drink  taken.  Ask  especially  about  the 
kind  of  pain  or  discomfort,  whether  burning,  sharp,  stabbing 
or  boring,  or  whether  dull  and  slight,  or  merely  a  sensation  of 
fullness  or  weight — a  bearing-down  feeling.  If  there  is  no 
pain,  find  out  if  the  patient  is  drows}'-  after  meals. 

Nausea  and  Vomiting.     Eructations. — Inquire  as  to  nausea 


70  METHODS    OF    EXAMINATION 

and  vomiting,  and  if  either  or  both  occur,  ascertain  definitely 
when  and  under  what  circumstances,  the  same  as  concerning 
pain.  Ask  then  whether  blood,  any  reddish  substance  or 
altered  blood  resembling  coffee  grounds,  is  ever  present,  either 
in  the  matters  vomited  or  in  the  stools.  Question  closely  as 
to  the  habit  of  eructation  or  belching,  but  as  some  patients 
belch  unconsciously,  ask  the  same  question  also  of  some  other 
member  of  the  family.  I  once  sat  next  at  table  to  a  lady  who 
rarely  finished  a  meal  without  bringing  up  more  or  less  noisily 
a  quantity  of  gas  from  her  stomach,  yet  later,  when,  being 
called  upon  to  prescribe  for  her,  I  inquired  as  to  eructations, 
she  replied  that  she  was  not  troubled  in  that  way.  Still, 
patients  are,  as  a  rule,  only  too  painfully  aware  of  the  symp- 
tom, and  eager  to  have  it  relieved.  Wdien  eructations  are 
complained  of,  learn  whether  or  not  the  eructated  gas  has  any 
taste  or  smell,  and  if  so  what  kind — also  whether  belching 
freely  usually  relieves  any  associated  gastric  pain. 

Bowel  Movements. — Question  with  special  care  about  the 
action  of  the  bowels,  whether  there  are  daily  normal  evacua- 
tions or  any  derangement  in  the  direction  of  either  constipa- 
tion or  diarrhea.  It  is  absurdly  insufficient  to  be  satisfied  with 
the  answer  that  the  bowels  are  "  regular."  An  instance  is  on 
record  of  a  woman  who  made  this  answer,  and  later  it  was 
found  that  she  had  one  movement  a  week,  which  occurred 
regularly  every  Sunday  n:orning  before  she  went  to  church. 
Ask  as  to  the  number,  color,  character,  and  form  of  the  stools 
passed  daily  or  every  other  day,  whether  or  not  mixed  or 
covered  with  blood,  mucus,  or  pus ;  as  to  the  presence  in  the 
stools  of  altered  blood,  resembling  coffee  grounds.  A  further 
point  of  diagnostic  importance  to  be  elicited  in  regard  to  blood 
accompanying  stools  is  whether  it  is  bright  red,  showing  an 
arterial  origin,  or  dark  red  but  fresh  looking,  pointing  then  to 
a  source  low  in  the  bowels  and  usually  signifying  hemorrhoids. 
Inquire  further  as  to  any  abnormality  accompanying  defeca- 
tion, such  as  discomfort,  pain,  or  straining.  If  diarrhea  be 
reported,  ascertain  whether  it  consists  of  merely  one  or  two 


THE    INTERROGATION    OF    THE    PATIENT  ^l 

loose  Stools  ill  the  morning  (the  so-called  morning  diarrhea) 
or  whether  the  loose  movements  are  more  frequent,  and  likely 
to  occur  at  any  time  of  the  day  or  night.  In  such  cases  learn 
definitely  about  the  color,  odor,  and  character  of  the  stools, 
whether  very  thin,  like  dishwater,  gruel-like,  soft  and  mushy, 
putty-like,  or  fully  formed — sausage-shaped ;  also  if  formed, 
whether  of  normal  size  or  small  and  narrow — of  finger  or  lead- 
pencil  size — as  in  spastic  constipation. 

Flatulency. — Inquire  regarding  the  presence  of  gas  in  the 
bowels,  the  times  when  it  most  frequently  occurs,  the  odor  of 
it,  whether  particularly  offensive  or  nearly  odorless,  the 
amount  of  it,  whether  slight  or  so  great  as  to  maintain  an 
almost  constant  rumbling  and  occasional  loud  explosions,  so 
as  to  keep  the  patient  out  of  society.  Ascertain  further  re- 
garding the  reaction  of  the  system  to  the  gas  formed,  that  is, 
whether  it  passes  rapidly  through  the  intestines  and  out  at  the 
anus  with  or  without  an  accompanying  stool,  or  is  long  re- 
tained in  some  one  or  more  pouches  which  are  greatly  over- 
distended,  with  pain  and  at  times  violent  colic  through  ir- 
regular contractions — cramp  pains — or  merely  sufficient  to 
produce  much  discomfort  by  day  with  insomnia  or  broken  sleep 
at  night. 

The  Genito-urinary  System. — Whatever  your  suspicions  or 
provisional  diagnosis  may  be,  you  should  neglect  none  of  the 
chief  systems  of  the  body  in  your  interrogation  of  the  patient. 
The  answers  may  bring  out  very  unexpected  symptoms,  thus 
leading  you  to  examine  or  have  examined,  and  possibly  find  an 
important  lesion  in,  a  region  which  would  otherwise  have  been 
wholly  neglected  with  the  result  of  an  incorrect  diagnosis. 
Inquire  concerning  micturition,  its  frequency  by  day  or  night, 
and  any  accompanying  pain,  discomfort,  delay  or  diffxculty; 
and  in  the  case  of  men,  the  character  of  the  stream  passed,  also 
as  to  pain  in  the  region  of  the  bladder  or  rectum,  referable  to 
either  hemorrhoids  or  a  diseased  prostate  gland  or  trouble  in 
the  seminal  vesicles.  In  the  case  of  both  men  and  women,  do 
not  fail  to  ask  particularly  regarding  sexual  matters,  except 


72  METHODS    OF    EXAMINATION 

when  the  patient  is  an  unmarried  woman.  An  enormous 
amount  of  disease  affecting  every  one  of  the  other  systems 
has  its  origin  in  faulty  sexual  hygiene,  and,  delicate  as  the 
subject  is,  the  physician  who  ignores  it  must  very  often  leave 
undiscovered  the  cause  and  nature  of  the  trouble  he  is  attempt- 
ing to  remedy,  with  a  resulting  failure  which  is  harmful  always 
and  sometimes  disastrous  to  both  his  patient's  health  and  his 
own  reputation.  Excessive  sexual  indulgence  is  doubtless 
common  enough,  and  the  cause  of  considerable  disease;  but 
masturbation,  the  abnormal  excitation  of  sexual  passion  with- 
out the  normal  satisfaction  of  it,  incomplete  coition,  that  is, 
the  act  interrupted  to  prevent  conception,  and  other  perversions 
or  abuses  of  the  reproductive  instinct,  are  all  exceedingly 
prevalent  and  result  indispLitably  in  a  very  large  amount  of  ill 
health.  If  you  will  question  all  married  persons  as  to  the 
number  of  children  they  have  had,  the  intervals  between 
pregnancies,  and,  when  these  have  been  exceptionally  long,  as 
to  any  methods  practiced  for  preventing  conception,  you  will  be 
surprised  at  the  number  of  respectable  and  otherwise  excellent 
and  intelligent  married  couples  wdio  have  for  years  been 
resorting  to  the  coitus  interruptns,  with  a  resulting  wrecking 
of  the  health  of  one  or  both,  including  nearly  always  the 
nervous  and  digestive  systems.  In  the  case  of  women,  besides 
interrogating  as  to  urinary  symptoms,  you  will,  of  course, 
inquire  concerning  pains  in  the  lower  back  and  pelvic  region, 
and  very  fully  as  to  the  menstrual  function,  whether  regular 
and  at  what  intervals,  the  amount  and  character  of  the  blood 
lost,  the  duration  of  the  periods,  and  whether  painful  or  not. 

When  there  is  suspicion  of  masturbation  or  abnormal  sexual 
excitation  in  any  form  you  will  need  to  exercise  much  discre- 
tion in  each  case  as  to  whether  it  is  better  to  ask  questions 
upon  the  subject  with  all  possible  delicacy,  or  to  convince  your- 
selves by  other  means  such  as  an  examination  of  the  genitals. 
Masturbation  usually  produces  certain  changes  in  them  and 
can  often  be  recognized  also  by  other  signs. 


LECTURE  V 

THE  PHYSICAL  EXAMINATION  OF  THE 
PATIENT 

General  Considerations. — After  a  full  and  systematic  inter- 
rogation of  the  patient,  you  may  or  may  not  have  ground  for 
suspecting  some  of  the  digestive  organs  to  be  involved.  If 
the  chief  complaint  has  been  of  indigestion,  or  of  any  irregu- 
larities or  abnormalities  connected  with  the  digestive  functions, 
whether  it  be  of  a  dry  mouth,  pointing  to  deficient  or  defective 
saliva  or,  at  the  other  end  of  the  alimentary  canal,  difficult  or 
painful  defecation,  it  will  be  desirable  to  make  an  examination 
of  the  entire  digestive  system,  for  deficient  saliva  impairs  the 
digestion  and  piles  usually  result  from  an  overworked  liver. 
The  cause  of  the  trouble,  even  in  these  cases,  however,  will 
often  be  found  elsewhere.  It  may  be  a  consequence  of  heart 
disease,  tuberculosis,  or  a  disorder  of  the  nervous  system  acting 
refiexly  upon  the  stomach  or  intestines.  After  an  exploration 
of  the  gastro-intestinal  organs  and  testing  the  stomach,  if  no 
abnormality  appears  to  exist  in  any  of  them,  you  will  naturally 
look  further  for  the  cause  of  the  malady. 

A  constant  coldness  of  the  hands  and  feet  would  indicate 
derangement  of  the  circulation,  but  by  no  means  necessarily 
heart  disease.  Much  oftener  it  is  due  to  a  contraction  of  the 
arterioles  resulting  from  an  excess  in  the  blood  of  xanthin 
bases  or  other  toxic  products  of  a  faulty  assimilation,  and  in 
all  such  cases  some  of  the  digestive  processes  are  imperfectly 
performed. 

But,  on  the  other  hand,  there  may  be  serious  disease  in  one 
or  more  parts  of  the  digestive  system  even  when  none  of  the 
symptoms   seem  to  point   in   that   direction.      For    instance, 

73 


74  METHODS    OF    EXAMINATION 

persistent  or  frequent  insomnia,  in  the  absence  of  pain  any- 
where in  the  body,  should  awaken  suspicion  of  a  digestive 
derangement,  especially  of  excessive  secretion  of  HCl,  sluggish 
intestinal  functions,  flatulency,  etc.,  and  pain  in  the  lower  back 
in  women  or  other  complaints  in  them  dependent  upon  a  dis- 
placement of  one  of  the  pelvic  organs,  should  lead  to  a  careful 
search  for  a  downward  displacement  of  the  stomach  and  trans- 
verse colon  with  or  without  a  coincident  ptosis  of  the  kidneys 
and  others  of  the  abdominal  organs,  since  these  latter  displace- 
ments very  frequently  precede  the  trouble  in  the  pelvis,  produc- 
ing by  a  direct  pressure  a  malposition  of  the  uterus. 

Whenever  you  have  reason  to  think,  that  some  part  of  the 
digestive  system  is  at  fault,  you  should  proceed  to  an  examina- 
tion of  the  organs  connected  therewith  in  an  orderly  and 
thorough  manner,  carefully  recording  the  results. 

Inspection. — Every  examination  properly  begins  with  in- 
spection. Naturally  you  will  first  look  the  patient  over  care- 
fully and  note  his  appearance,  the  tint  of  the  skin  and  condi- 
tion of  nutrition  generally — i.  e.,  whether  he  is  of  'full  habit 
and  plump  with  smooth  rosy  skin  and  pink  cheeks,  or,  on  the 
contrary,  thin,  emaciated,  wrinkled  prematurely,  pale  or 
sallow,  etc.  You  could  scarcely  fail  to  notice  also  whether  the 
expression  is  one  of  cheerfulness  and  contentment  or  whethei 
it  shows  pain,  anxiety,  worry,  or  depression.  Dyspeptics  are 
most  likely  to  present  the  latter  aspects,  especially  if  their 
dyspepsia  depends  upon  an  organic  lesion  or  serious  functional 
derangement  of  long  standing,  though  in  some  cases  of 
hysteria  and  in  a  smaller  percentage  of  cases  of  neurasthenia 
with  sympathetic  disturbance  of  the  digestion,  there  may  for  a 
long  time  be  good  general  nutrition  with  a  well-rounded  form 
and  the  bloom  of  health.  A  similar  robust  appearance  may 
coexist  with  gastric  catarrh  or  round  ulcer  of  the  stomach  in 
their  earlier  stages.  As  a  rule  patients  who  have  suffered  for 
several  years  with  decided  indigestion  whether  from  organic 
or  so-called  functional,  reflex,  or  sympathetic  causes,  show  a 
lowered  nutrition,  not  possessing  either  a  ruddy  complexion 


THE    PHYSICAL    EXAMINATION    OF    THE    PATIENT  75 

or  the  usual  amount  of  adipose  tissue,  but  there  are  many  ex- 
ceptions, especially  as  to  adiposity. 

After  such  a  general  inspection,  you  should  look  carefully 
into  the  oral  cavity  and  note  very  particularly  the  condition  of 
the  lips,  tongue,  teeth,  gums,  and  pharynx.  The  tongue  may 
sometimes  be  clean  and  natural  looking  in  spite  of  the  fact 
that  a  considerable  catarrhal  process  exists  in  the  stomach  or 
intestines,  and  in  general  its  appearance  may  depend  upon 
the  condition  of  the  pharynx  or  upon  that  of  any  of  the 
structures  below.  It  is  probable,  too,  that  catarrh  of  the 
duodenum,  quite  as  often  as  a  similar  process,  in  the  stomach, 
is  accompanied  by  a  furring  of  the  tongue.  Whenever,  how- 
ever, the  tongue  is  coated,  there  is  trouble  somewhere  requiring 
attention — either,  as  is  most  usual,  in  the  alimentary  tract,  or 
else  deficient  excretion  through  the  kidneys  relative  to  the 
amount  of  poisons  to  be  excreted.  If  it  results  from  a 
catarrhal  inflammation  in  the  pharynx,  it  is  still  important, 
since  the  latter,  when  allowed  to  run  on,  tends  ultimately  to 
involve,  both  by  continuity  and  by  infection  through  the 
swallowed  mucus,  the  esophagus,  stomach,  and  intestines. 

Without  a  sufficient  number  of  properly  opposed  teeth  to  do 
good  chewing,  there  cannot  be  a  satisfactory  digestion.  De- 
caying teeth  and  diseased  gums  are  often  the  unsuspected  cause 
of  troublesome  inflammatory  conditions  in  the  stomach.  I 
have  encountered  numerous  cases  of  chronic  gastritis  which 
yielded  promptly  after  the  mouth  had  been  cleared  of  rotten 
stumps  of  teeth,  or  a  purulent  process  in  the  gums  had  been 
cured.  Boas  reports  cases  of  gastric  catarrh  which  were 
treated  ineffectually  for  years,  but  quickly  responded  after 
remedying  a  chronic  inflammation  of  the  pharynx. 

The  uncovered  thorax  and  abdomen  should  next  be  closely 
inspected,  never  neglecting  the  precordial  region,  since  heart 
disease  so  generally  disorders  the  digestion,  producing  a  stasis 
in  the  liver  and  viscera  with  constipation,  hemorrhoids,  etc. 
Note  whether  the  apex  beat  is  in  its  normal  site  in  the 
fifth  interspace  inside  the  nipple  line,  or  further  out  or  lower 


76  METHODS    OF    EXAMINATION 

down,  as  in  hypertrophy  or  dilatation,  and  also  whether  there 
is  bulging  of  the  chest  wall  directly  over  the  heart,  increase  in 
the  width  of  the  intercostal  spaces  on  the  left  side,  or  a  forward 
projection  of  the  lower  end  of  the  sternum,  as  may  often  be 
seen^n  marked  cardiac  enlargements. 

Inspection  of  the  abdomen,  though  inferior  to  palpation  and 
percussion,  is  one  of  the  useful  methods  of  examination  and 
often  affords  valuable  information.  It  should  never  be 
neglected  when  any  digestive  disorder  is  suspected.  Even  with- 
out inflating  the  stomach  or  colon  (procedures  the  technique 
and  results  of  which  I  shall  discuss  later)  much  can  be  learned 
by  a  critical  survey  of  the  entire  region  bared  of  covering. 
The  relaxed,  flabby,  and  pendulous  abdomen  of  the  woman  who 
has  borne  many  children,  or  been  formerly  very  obese,  but 
subsequently  lost  her  flesh  through  ill  health,  not  through 
exercise,  will  contrast  markedly  with  the  firm,  symmetrically 
rounded  form  of  the  woman,  young  or  old,  who,  whether  she 
is  a  nullipara  or  a  multipara,  and  whether  she  was  at  one  time 
obese  or  not,  has  kept  her  trunk  muscles  in  good  condition  by 
physical  training  as  well  as  by  the  avoidance  of  tight  corsets 
and  of  all  luxurious  enervating  habits.  If  there  is  not  too 
thick  a  layer  of  adipose  tissue,  and  any  of  the  viscera  happen  to 
be  distended  with  gas,  their  outlines  may  frecjuently  be  de- 
termined by  inspection  without  the  help  of  palpation  or  percus- 
sion. Inspection  may  reveal  a  separation  of  the  recti  abdom- 
inalis  muscles,  especially  when  the  patient  is  obese  and  the  in- 
testines are  full  of  gas.  There  is  often  a  bulging  outward  then 
of  the  abdominal  wall  between  the  separated  muscles.  If  the 
patient  stands  up  while  the  abdomen  remains  exposed  to  view, 
any  marked  existing  sagging  (ptosis)  of  the  viscera  may  be 
recognized.  Such  a  displacement  includes  often  the  stomach, 
colon,  and  small  intestines,  with  frequently  one  or  both  kidneys 
(the  right  one  especially),  and  sometimes  the  liver  and  spleen 
may  be  recognized  by  the  prominent  bulging  which  would  then 
show  below  the  umbilicus  (splanchnoptosis).  Skilled  palpa- 
tion in  such  cases  will  generally  demonstrate  the  right  kidney 


THE    PHYSICAL    EXAMINATION    OF    THE    PATIENT  T] 

(and  sometimes  both  kidneys)  to  be  movable.  Exceptionally 
the  liver  and  spleen  will  also  be  found  to  be  displaced  down- 
ward, but  it  is  rare  that  any  one  of  these  ptoses  occurring  by 
itself,  except  those  of  the  stomach  and  intestines,  is  visible. 
A  far  advanced  tumor  of  one  of  the  viscera  may  also,  some- 
times, be  manifest  at  a  glance.  In  thin  persons  peristaltic 
movements  may  often  be  observed  over  the  stomach  and  intes- 
tines, particularl}^  when  the  motor  function  has  been  in  some 
way  disturbed. 

Note  particularly  the  appearance  of  the  abdominal  veins, 
whether  or  not  swollen  and  tortuous  and  the  amount  of  such 
swelling  and  tortuosity.  The  latter  condition  is  significant  of 
an  obstruction  to  the  return  of  the  portal  blood  from  the 
abdominal  structures,  and  indicates  frequently  cirrhosis  of  the 
liver,  though  pressure  from  tumors  may  sometimes  produce 
the  same  condition.  The  presence  of  fluid  in  the  peritoneal 
cavity  (ascites),  when  in  large  amount,  may  be  detected  by 
inspection,  the  whole  abdomen  being  symmetrically  enlarged, 
especially  in  its  lower  part  when  the  patient  stands,  and  in  the 
flanks  more  particularly  when  he  is  lying  on  the  back,  although 
when  the  accumulation  is  extremely  large,  the  abdominal  walls 
may  be  so  fully  distended  that  there  is  little  change  in  their 
appearance  in  the  two  different  positions.  The  bulging  below 
the  line  of  the  umbilicus,  in  cases  of  general  sagging  of  the 
viscera  (splanchnoptosis),  differs  from  the  swelling  in  a  case 
of  moderate  ascites  chiefly  in  that  the  bulging  in  the  former  is 
more  central  and  does  not  change  so  greatly  upon  the  recum- 
bent position  being  assumed. 

Palpation. — Palpation  is  one  of  the  most  important  methods 
of  examination  and  is  a  difficult  one  in  which  to  become  expert. 
Good  training  and  much  experience  are  both  necessary  to  fit 
the  clinician  for  accomplishing  accurate  results  by  means  of  it, 
but  the  art,  once  acquired,  is  of  the  greatest  value,  especially  in 
the  exploration  of  the  abdominal  viscera.  For  palpation  in 
this  region,  place  the  patient  in  a  recumbent  position  with  the 
knees  flexed  over  a  pillow.     To  palpate  well  you  will  need  to 


78  METHODS    OF    EXAMINATION 

keep  your  lingers  soft  and  smooth  on  their  pahnar  surfaces 
and  be  sure  that  they  are  warm;  for  nothing  is  so  hkely  to 
provoke  embarrassing  resistance  through  involuntary  contrac- 
tions of  the  muscles  overlying  the  parts  being  explored  as 
coldness  of  the  palpating  fingers.  Feel  very  gently  first  over 
the  surface  with  the  flat  of  one  hand  constantly  in  contact  with 
the  abdomen,  employing  at  first  the  lightest  touch,  and  then 
afterward,  when  the  parts  have  become  more  accustomed  to 
the  manipulations,  gradually  insinuate  the  tips  of  your  fingers 
deeply  down  into  the  cavity,  until  finally  you  may  often  be 
able  with  one  hand  superimposed  over  the  other,  to  bring 
them  into  contact  successively  with  the  various  structures  upon 
the  back  wall  of  the  abdomen.  This  should  enable  you  to 
recognize  marked  abnormalities  of  these  structures,  including 
the  appendix  vermiformis,  as  to  size,  position,  and  degree  of 
hardness,  also  to  determine  the  existence,  situation,  and  size  of 
tumors  in  the  abdominal  cavity.  Xote  any  unusual  resistance, 
but  be  very  careful  not  to  be  misled  by  contractions  in  the 
recti  muscles. 

Indeed,  the  condition  of  the  abdominal  muscles  generally, 
as  to  their  relative  tonicity  and  reflex  excitability,  varies 
greatly  in  different  patients,  as  well  as  in  the  same  patient  at 
different  times.  This  has  important  bearings  upon  the  diag- 
nosis and  treatment.  In  persons  of  normal  nerve  tone  it 
should  be  possible  by  diverting  their  attention,  as  by  conversa- 
tion during  gentle  palpation,  to  obtain  sufficient  muscular 
relaxation  for  very  satisfactory  results.  One  may  then  feel 
through  even  the  well-developed  recti  muscles  and  determine 
the  condition  of  structures  beneath  them.  When  there  is 
marked  flabbiness  of  all  the  muscles,  as  in  many  persons  with 
ptoses,  without  unduly  heightened  reflexes,  palpation  is  un- 
usually easy  and  fruitful  in  results.  On  the  other  hand, 
various  degrees  of  increased  reflex  excitability  will  be  found 
in  the  abdominal  muscles  of  patients,  and  in  some  this  is  so 
extreme  that  upon  the  first  attempts  at  palpation  the  muscles 
instantly   stift'en,   becoming  board-like    in   their   rigidity.     In 


THE    PHYSICAL    EXAMINATION    OF    THE    PATIENT  79 

these  cases  palpation  reveals  almost  nothing  except  the  bare 
fact  that  there  is  a  peculiarly  excitable  nervous  and  muscular 
system,  from  which  you  may  generally  infer  the  existence  of 
neurasthenia  with  probably  also  spastic  constipation,  and  very 
often,  though  not  necessarily,  excessive  secretion  of  HCl 
in  the  stomach.  But  even  in  these  cases  you  may  often  succeed 
after  the  patient's  nervousness  has  been  calmed.  By  gentle 
friction  with  well-warmed  hands  over  the  abdomen  and 
patiently  persisting,  it  is  frequently  possible  to  make  finally  a 
fairly  satisfactory  palpation,  even  when  at  first  the  slightest 
pressure  of  the  finger  tips  was  opposed  by  a  vigorous  muscular 
contraction. 

To  map  out  and  explore  by  palpation  the  less  deeply  placed 
organs  of  the  abdominal  cavity  the  left  hand  should  be  used 
to  push  the  organ  toward  the  palpating  hand  and  hold  it  in 
position,  while  the  fingers  of  the  latter  are  made  to  pass  lightly 
over  and  around  it.  By  a  form  of  this  bimanual  palpation 
either  kidney  can  be  very  easily  felt,  when  sufficiently  movable 
to  appear  even  in  part  below  the  ribs.  To  examine  the  right 
kidney,  the  examiner  sits  on  the  right  side  of  the  patient.  His 
left  hand  is  pressed  against  the  site  of  the  kidney  from  behind 
while  his  right  hand  is  pushed,  gently  but  deeply,  down  into  the 
abdominal  cavity  from  in  front  just  to  the  right  of  the  median 
line  and  directly  under  the  level  of  the  lowest  rib,  the  fingers 
of  this  hand  being  directed  downward  and  outward.  Then,  if 
the  kidney  be  not  loose,  the  fingers  of  the  two  hands  will  meet 
with  nothing  but  the  anterior  and  posterior  walls  of  the  trunk 
between  them.  But  if  the  kidney  is  movable  it  may  be  recog- 
nized and  grasped  as  it  emerges  from  behind  the  ribs  during 
a  full  inspiration,  and,  returning,  can  again  be  felt  to  pass 
through  the  fingers  with  expiration.  The  pressure  should  be 
light  during  inspiration  so  as  to  let  the  kidney  descend,  but 
strong  at  the  end  of  inspiration  to  retard  the  kidney's  return. 
To  examine  the  left  kidney  the  physician  should  be  on  the 
left  side  of  the  couch  or  examining  table,  and  the  positions 
of  the  bands   are   reversed.     A  movable  or  prolapsed   kid- 


8o  METHODS    OF    EXAMINATION 

ney  is  often  very  sensitive  and  should  not  be  roughly 
handled. 

For  a  fuller  account  of  the  method  of  palpating  the  kidneys 
with  an  illustration  of  the  method,  see  Lecture  XL.,  on  Mov- 
able Kidneys. 

The  position  and  size  of  the  stomach  and  its  pyloric  end 
can  sometimes  be  made  out  by  palpation  alone,  and  it  must  be 
our  main  dependence  for  the  determination  of  the  thickness 
of  the  walls  of  these  structures.  The  same  is  true  as  to  the 
colon,  especially  its  transverse  portion,  which  is  often  pal- 
pable. Fecal  concretions  and  accumulations  may  usually  be 
felt  in  patients  who  are  not  too  stout.  Downward  dis- 
placements of  the  liver  and  spleen  (which,  however,  occur  only 
exceptionally,  while  the  right  kidney,  in  women  particularly,  is 
very  frecjuently  thus  displaced)  may  be  recognized  by  palpation 
as  well  as  by  percussion.  Unusual  mobility  of  the  tenth  rib 
through  a  lack  of  its  proper  attachment  to  the  rib  above  will 
be  found  at  times  in  neurasthenic  persons,  and  is  considered 
by  Stiller  a  valuable  sign  of  what  he  holds  to  be  a  con- 
genital tendency  to  neurasthenia  and  relaxed  muscles  gen- 
erally.^ 

Supplementing  palpation  by  pressure  with  the  finger-tips 
assists  in  making  the  diagnosis  of  various  abdominal  diseases. 
When  such  pressure  causes  acute  pain  over  small  circumscribed 
areas  it  must  always  awaken  the  suspicion  of  ulcer;  or  it  may 
signify  appendicitis  when  the  tender  spot  is  over  McBurney's 
point  in  the  cecal  region.  If  the  sensitive  area  is  in  the  epigas- 
tric region,  especially  just  below  the  ensiform  process  of  the 
sternum,  or  if  it  is  over  or  to  the  left  of  the  tenth,  eleventh, 
or  twelfth  thoracic  vertebra,  the  ulcer,  if  present,  would  usually 
be  in  the  stomach;  if  a  little  to  the  right  of  the  median  line  in 
front,  and  somewhat  lower  down,  it  would  be  more  likely  to 
indicate  duodenal  ulcer  in  any  case  presenting  other  symptoms 
of  ulcer  in  that  locality,  including  the  passage  of  stools  con- 
taining altered  blood.  An  acutely  sensitive  spot  over  the 
1  Arch.f.   Verdaimngskrankh.,  vol.  vii.  p.  375. 


THE    PHYSICAL    EXAMINATION    OF    THE    PATIENT  8 1 

cecum,  especially  if  near  McBurney's  point,  might  signify 
either  ulcer  or  appendicitis,  though  it  might  mean  merely 
catarrh  of  the  cecum.  In  the  case  of  even  chronic  catarrhal 
appendicitis  a  swelling  can  usually  be  made  out  by  the  skilled 
diagnostician  in  a  patient  who  is  not  very  stout. 

A  lesser  degree  of  sensitiveness  to  pressure,  particularly  if 
more  diffused,  would  suggest  the  possibility  of  a  chronic 
catarrhal  inflammation  of  the  viscus  underneath,  though  it 
might  be  due  to  a  hyperaesthetic  condition  of  one  of  the 
plexuses  of  the  sympathetic,  or  indicate  nothing  more  serious 
than  a  highly-wrought  and  oversensitive  nervous  system.  But 
in  the  latter  case  you  would  generally  find  a  similar  hyper- 
sesthesia  over  most  parts  of  the  abdomen  and  possibly  even 
over  the  thorax  or  arms. 

Palpation  over  the  spinal  vertebrse  and  ever  the  regions  on 
either  side  of  the  vertebrae,  where  the  spinal  nerves  emerge 
from  the  intervertebral  foramina,  is  also  highly  important  in 
many  cases.  All  authorities  upon  diseases  of  the  stomach 
recognize  the  importance  of  palpation  over  the  lower  dorsal 
spine  in  suspected  gastric  ulcer.  When  ulcer  is  present  in  the 
stomach  there  are  nearly  always  spots  painful  to  pressure, 
either  over  or  more  frequently  to  the  left  of  one  or  more  of 
the  vertebrae  between  the  eighth  dorsal  and  the  first  lumbar. 
In  my  experience  these  spots  are  oftenest  found  just  to  the 
left  of  the  eleventh  or  twelfth  dorsal  vertebrae. 

It  does  not,  however,  seem  to  be  generally  recognized  that 
chronic  disease  in  any  part  of  the  gastro-intestinal  tract  is 
likely  to  be  accompanied  by  sensitiveness  to  pressure  over  or 
along  the  side  of  the  spinal  vertebrae  corresponding  to  the 
points  of  emergence  of  the  spinal  nerves  which  contain  fibers 
supplying  the  viscera  involved.  The  late  Dr.  Hammond,  in  his 
work  on  "  Diseases  of  the  Nervous  System,"  devoted  much 
space  to  an  account  of  the  nerve  affection  known  in  that  day  as 
spinal  irritation,  and  in  the  course  of  that  account  called  atten- 
tion to  the  fact  that,  when  any  portion  of  the  spine  :s  sensitive 
to  pressure,  the  viscera  supplied  by  nerves  passing  out  from  the 


82  METHODS    OF    EXAMINATION 

spine  in  the  same  region  are  often  found  to  present  abnormal 
conditions. 

He  quoted  from  numerous  authors  views  similar  to  his  own, 
and  all  seem  to  have  considered  the  coincident  visceral  disturb- 
ances as  results  rather  than  causes  of  the  spinal  condition. 
Dr.  Hammond  ^  quoted  one  writer  as  follows : 

"  Mr.  J.  R.  Player  was  among  the  first  English  physicians, 
if  not  the  very  first,  to  call  attention  to  the  fact  that  eccentric 
derangement  of  function  may  be  the  result  of  irritation  of  the 
spinal  cord.  Thus  he  says :  '  Most  medical  practitioners  who 
have  attended  to  the  subject  of  spinal  disease  must  have  ob- 
served that  its  symptoms  frequently  resemble  various  and  dis- 
similar maladies,  and  that  commonly  the  function  of  every 
organ  is  impaired  whose  nerves  originate  near  the  seat  of 
disorder.  The  occurrence  of  pain  in  distant  parts  forcibly 
attracted  my  attention,  and  induced  frequent  examination  of 
the  spinal  column;  and  after  some  years'  attention  I  considered 
myself  enabled  to  state  that  in  a  great  number  of  diseases 
morbid  symptoms  may  be  discovered  about  the  origins  of  the 
nerves  which  proceed  to  the  affected  parts,  or  of  those  spinal 
branches  which  unite  them;  and  that,  if  the  spine  be  examined,, 
more  or  less  pain  will  commonly  be  felt  by  the  patient  on  the 
application  of  pressure  about  or  between  those  vertebrae  from 
which  such  nerves  emerge.'  " 

Dr.  Hammond  himself  gave  the  following  directions  for 
carrying  out  an  examination  of  the  spine : 

"  To  ascertain  Avhether  or  not  the  tissues  outside  of  the 
spinal  canal  are  in  a  state  of  hyper?esthesia,  the  pressure  should 
be  applied  with  gradually  increasing  force,  b)'  means  of  the 
thumbs  applied  to  the  spinous  processes  and  the  intervertebral 
spaces,  as  recommended  by  Flint.  The  examination  should 
be  thorough  and  extend  throughout  the  whole  extent  of  the 
vertebral  column.  The  fact  that  the  patient  denies  the  ex- 
istence of  tenderness  should  have  no  weight  with  the  physi- 

'"  Diseases  of  the  Nervous  System,"  by  Wm.  A.  Hammond,  M.  D., 
New  York,  1876,  p.  387. 


THE    PHYSICAL    EXAMINATION    OF    THE    PATIENT  83 

cian."  Continuing,  Dr.  Hammond  described  the  case  of  a 
lady  who  had  been  treated  several  years  unsuccessfully  for  dys- 
pepsia and  denied  having  any  spinal  tenderness.  He  found 
three  very  tender  spots  on  her  spine,  and  applying  local  treat- 
ment to  them,  effected  a  cure.  Dr.  Still,  originator  of  the 
so-called  osteopathic  treatment,  seems  to  have  enlarged  upon 
these  observations  of  Hammond,  Player  and  others  relative 
to  the  spine  and  spinal  nerves,  and,  combining  with  their 
methods  other  manipulations,  including  some  of  those  usually 
employed  by  masseurs,  sought  to  establish  a  new  system  of 
medical  practice  from  which  medicines  should  be  entirely 
excluded.  But  already  his  followers  have  found  the  system 
too  narrow,  and  a  number  of  their  schools  are  now  beginning 
to  teach  materia  medica,  just  as  the  ablest  and  most  con- 
scientious homeopaths  have  abandoned  an  exclusive  depend- 
ence upon  infinitesimals. 

Dr.  John  P.  Arnold  has  called  attention  to  a  novel  objective 
sign  which  may  be  recognized  upon  palpation  over  the 
sensitive  regions  alongside  the  spinal  vertebrse,  and 
sometimes  in  such  regions  which  are  not  sensitive  to  pressure, 
though  in  all  cases  he  maintains  that  the  part  of  the  body  sup- 
plied by  the  vaso-motor  nerve  fibers  emerging  in  the  corre- 
sponding intervertebral  space  will  be  found  to  present  some 
abnormal  condition.  The  peculiarity  described  by  him  is,  in 
such  cases,  a  somewhat  doughy,  and  in  chronic  ones,  a  gristly, 
tense,  cord-like  feeling  of  the  band  of  longitudinal  muscular 
fibers  which  are  found  on  either  side  of  the  spine.  This 
abnormality  is  supposed  by  Arnold  to  be  due  to  a  con- 
gested or  infiltrated  condition  of  the  muscle  while  the  cord  itself 
is  anaemic,  probably,  in  chronic  cases.  Hammond  believed  the 
spinal  cord  to  be  ansemic  in  such  cases.  The  findings  obtained 
by  a  careful  palpation  over  the  spine  should  thus  assist  in 
directing  our  attention  to  the  organ  or  part  of  the  body  which 
may  be  suspected  of  being  diseased. 

You  should  make  it  a  rule  to  examine  carefully  the  spines 
of  all  chronic  invalids  by  pressing  deeply  with  the  finger-tips 
(or  with  the  thumbs,  as  Flint  advised)  close  to  the  vertebrae 


84  METHODS    OF    EXAMINATION 

and  then  exert  gentle  traction  in  a  lateral  direction  outward 
from  the  spine  on  either  side.  The  patient  should  be  lying 
upon  his  right  side  while  you  palpate  along  the  left  side  of 
the  vertebrae,  and  should  then  change  to  his  left  side  in  order 
that  you  may  palpate  upon  the  right  side  of  the  latter,  so 
that  the  tissues  may  be  in  the  utmost  condition  of  relaxation 
practicable.  In  both  cases  you  will  find  it  best  to  stand  in 
front  of  the  patient  and  reach  over  his  upper  side  to  make 
palpation  along  the  region  of  the  upper  side  of  the  spinal 
column. 

In  numerous  patients,  especially  those  suffering  from  digest- 
ive derangements,  you  will  be  likely,  while  palpating  in  the 
way  described,  to  recognize  in  the  longitudinal  muscles  run- 
ning parallel  and  close  to  the  spine  the  tense,  cord-like  sen- 
sation above  mentioned.  If,  simultaneously  with  your  recogni- 
tion of  such  a  condition,  the  patient  complains  of  sensitiveness 
in  the  same  regions,  the  accuracy  of  your  finding  will  be  at 
once  confirmed. 

By  noting  in  Lecture  II.  concerning  the  anatomy  and 
physiology  of  the  nerve  supply  of  the  stomach  and  in- 
testines to  what  part  of  the  tract  the  vaso-motor  nerves  are 
supplied  which  emerge  from  that  segment  of  the  spine  near 
which  the  tenderness  and  signs  above  described  can  be  made 
out,  you  will  be  enabled  to  direct  your  suspicions  to  the  organ 
or  part  thus  supplied.  For  example,  if  you  can  find  this  sign 
by  palpating  alongside  of  any  of  the  lower  dorsal  vertebrae, 
and,  especially  if  there  is  sensitiveness  also  to  pressure  in  the 
same  place,  you  should  suspect  some  disease  in  the  stomach,  or 
possibly  in  the  small  intestines;  but  it  might  signify  disease 
in  the  liver  or  pancreas,  either  alone  or  in  conjunction  with  an 
involvement  of  the  stomach  and  small  intestines,  since  the 
vaso-constrictors  which  supply  all  of  these  organs  are  found 
in  some  of  the  spinal  nerves,  from  the  fifth  dorsal  to  the 
second  lumbar. 


THE    PHYSICAL    EXAMINATION    OF    THE    PATIENT  85 

AUSCULTATION   AND   PERCUSSION 

Auscultation  plays  a  comparatively  small  part  in  the  exami- 
nation of  the  abdominal  organs,  yet  it  can  be  made  to  afford 
information  of  value.  When  one  drinks,  a  swallowing  sound 
may  often  be  heard  over  the  ensiform  process  and  normally 
about  seven  seconds  later  a  second  sound  caused  by  the  passage 
of  the  liquid  into  the  stomach.  But  in  cancerous  or  other  ob- 
struction of  the  cardiac  orifice  of  the  stomach,  as  well  as  in  the 
case  of  obstruction  of  the  esophagus  from  any  cause,  Ihere  is 
usually  a  delay  in  the  passage  of  food  or  drink  into  the  viscus, 
and  auscultation  with  a  stethoscope  of  the  second  swallowing 
sound  generally  shows  then  a  prolongation  by  eight  to  ten  sec- 
onds of  the  ordinary  time  required  for  this  sound  to  be  audible 
after  the  subject  has  swallowed.  When  the  obstruction  is 
marked,  the  swallowing  sounds  may  not  be  heard  at  all.  But 
this  sign  is  not  very  reliable.  The  first  sound  is  very  often  not 
audible  in  health,  and  the  second  swallowing  sound  may  ex- 
ceptionally be  delayed  in  health,  and  instances  are  on  record 
of  its  having  been  heard  at  the  normal  time  when  cancer  of 
the  cardia  was  present,  though  probably  in  an  early  stage. 

Auscultation  of  percussion  and  friction  sounds  (called  aus- 
cultatory percussion  and  auscultatory  friction)  afford  a  very 
delicate  method  of  determining  boundaries,  as  will  be  described 
in  Lecture  VI.  under  the  head  of  Summary  of  Author's  Method. 

Percussion  is  the  most  convenient  and  generally  serviceable 
of  all  the  methods  of  determining  the  size  and  position  of  the 
abdominal  organs,  and  when  with  this  are  conjoined  in- 
spection and  palpation,  as  well  as  auscultation  of  the  splashing 
sound  elicited  by  light  tapping  with  the  finger  tips  (clapote- 
ment),  sufficiently  exact  results  are  as  a  rule  obtainable  for  all 
clinical  purposes.  A  more  particular  description  of  percussion 
appears  in  Lecture  VI. ,  under  the  title  of  "  The  Author's 
Method  of  Outlining  the  Stomach,"  etc. 

Instruments  for  Determining  the  Size  and  Position  of  the 
Viscera. — Numerous  ingenious  forms  of  apparatus  have  been 


86  METHODS    OF    EXAMINATION 

(IcNi'sed  with  the  idea  of  accomplishing  these  results  more 
accurately.  Einhorn's  gastrodiaphane,  one  of  the  best  of 
these,  consists  of  a  small  electric  lamp  placed  at  the  extremity 
of  what  is  virtually  a  stomach  tube,  through  which  pass 
rheophores  connecting  the  lamp  with  a  battery  outside.  After 
the  patient,  with  bared  abdomen,  has  drunk  one  or  two  glasses 
of  water  the  instrument  is  introduced  into  the  stomach,  the 
room  having  first  been  darkened,  and  the  current  is  turned  on. 


Fig.  14. — Einhorn's  gastrodiaphane. 

When  the  abdominal  wall  is  not  too  thick,  a  glow  of  light  can 
then  usually  be  seen  over  and  for  two  or  three  inches  around 
the  situation  of  the  lamp.  By  having  the  patient  assume  differ- 
ent positions,  the  lamp  can  generally  be  caused  to  fall  to  the 
lowest  part  of  the  stomach  and  move  from  side  to  side,  so  as 
to  show  appnjximately  the  lower  boundary  of  the  stomach. 
Certain  authors  maintain  that  while  this  is,  on  the  whole,  a  sat- 
isfactory means  of  mapping  out  the  stomach,  it  is  liable  to 
mislead  by  the  glow^  of  light  appearing  most  conspicuously 
some  inches  above,  below,  or  to  one  side  of  the  actual  site  of 
the  lamp.  It  is  a  pretty  method  for  class  demonstration,  and 
is  very  con N'incing  to  the  friends  of  patients  who  might  other- 
wise be  skeptical  as  to  the  accuracy  of  a  diagnosis  of  enlarge- 
ment or  displacement  of  the  stomach.  The  gastrodiaphane 
has  pnjvcd  (jf  value  according  to  my  experience,  especially  as 
an  aid  in  determining  whether  a  tumor  felt  in  the  region  of 
the  stomach  is  in  the  anterior  or  posterior  wall.     When  it  is 


THE    PHYSICAL    EXAMINATION    OF    THE    PATIENT  8/ 

in  the  former,  and  the  lamp  can  be  placed  behind  it,  there 
appears  a  shadow  in  the  patch  of  transmitted  light.  (See 
Figure  No.  14.) 

Dr.  F.  B.  Turck  of  Chicago  has  invented  a  revolving  sound 
with  a  piece  of  sponge  fastened  to  its  distal  extremity, 
for  the  purpose  of  cleansing  effectually  the  walls  of  the 
stomach  in  cases  of  stubborn  gastric  catarrh,  in  which  the 
secretions  are  often  very  viscid  and  adherent.  This,  by  means 
of  a  simple  crank  mechanism  attached  to  the  upper  end  of  the 
sound,  is  made  to  revolve  and  in  doing  so  is  moved  from  one 
end  of  the  stomach  to  the  other,  following  first  the  greater 
and  then  the  lesser  curvature.  The  inventor  observed  that  the 
instrument,  as  it  wabbled  its  way  around  inside  the  organ, 


Fig.  15. — Turck's  gyromele. 

could  be  very  plainly  palpated  from  the  outside  by  the  exam- 
iner while  an  assistant  turned  the  crank.  In  this  manner  the 
instrument,  which  Turck  named  the  gyromele,  affords  prob- 
ably the  most  exact  and  reliable  information  obtainable  with 
regard  to  the  boundaries  of  the  stomach.     (See  illustration.) 

In  my  earlier  examinations  of  gastric  cases  I  made  use  of 
the  gyromele  frequently,  but  with  increasing  experience  in  the 
employment  of  the  convenient  and  altogether  satisfactory 
methods  described  hereinafter,  I  now  rarely  find  myself  in 
need  of  any  intragastric  instrument  to  determine  with  an 
all-sufficient  exactness  the  position  and  size  of  the  stomach. 

Both  the  electrodiaphane  and  the  gyromele  have  been  used 


88 


METHODS    OF    EXAMINATION 


to  assist  in  determining  the  position  and  size  of  various  por- 
tions of  the  colon.  With  a  reasonable  amount  of  skill  in  the 
manipulation  of  them,  they  may  prove  very  useful  for  these 
purposes,  even  though  not  often  indispensable.  By  inflating  the 
colon  with  air  after  emptying  it  thoroughly  of  feces,  its  posi- 
tion and  the  size  of  its  different  parts  can  usually  be  made  out 
with  sufficient  accuracy,  when  the  stomach  has  previously  been 
filled  with  fluid.  However,  in  doubtful  cases  in  which  extreme 
precision  in  diagnosis  is  important,  and  especially  when  there 
is  reason  to  suspect  very  anomalous  displacements,  you  should 


Fig.  i6. — Electric  gastroscope. 

know  how  to  avail  yourselves  of  the  confirmatory  results  ob- 
tainable by  these  very  ingenious  instruments. 

A  great  variety  of  instruments  has  been  designed  for  the 
inspection  of  the  rectum  and  sigmoid  flexure.  Illustrations  of 
some  of  the  more  useful  ones  are  given  in  the  lecture  devoted 
to  Diseases  of  the  Rectum  and  Anus.  For  the  examination  of 
the  colon  generally  the  x-rays  can  be  employed  after  previ- 
ously injecting  one  or  two  quarts  of  warm  water  containing  in 
suspension  subcarbonate  of  bismuth,  about  one  ounce  to  the 
quart.  All  the  bismuth  salts,  however,  are  now  believed  to 
be  capable  of  producing  toxic  effects  in  very  susceptible  per- 


THE    PHYSICAL    EXAMINATION    OF    THE    PATIENT  89 

sons,  when  administered  in  the  extremely  large  doses  nec- 
essary for  good  x-ray  pictures,  numerous  cases  of  poisoning 
by  them  having  been  reported;  but  the  subcarbonate  is  prob- 
ably the  safest  of  them.  Magnetic  oxide  of  iron  has  recently 
been  recommended  as  a  substitute  for  bismuth  in  x-ray  work. 
It  is  said  to  be  wholly  free  from  toxic  properties.  By 
means  of  the  x-rays  the  conditions  existing  in  the  lower 
colon,  as  to  position,  etc.,  can  be  very  clearly  made  out  when 
a  soft  rubber  rectal  tube,  having  a  flexible  cable  inside  of  it, 
has  been  previously  introduced. 

Various  other  instruments  have  been  invented  and  are 
sometimes  employed  by  gastrologists  in  the  examination  of 
the  stomach  and  other  viscera  and  for  testing  their  motor 
power,  but  most  of  these  are  not  indispensable.  The  gastro- 
scope,  a  metal  tube  devised  with  the  idea  of  affording  a  view 
of  the  inside  of  the  stomach,  is  not  safe  for  general  use,  and 
even  specialists  rarely  introduce  it.  It  can  give  information 
of  value  in  some  cases,  but  cannot  be  introduced  even  by  the 
most  expert  without  causing  the  patient  much  pain  and  in- 
volving some  risk.  An  illustration  of  an  improved  electric 
gastroscope  is  herewith  shown.  However,  since  the  publica- 
tion of  the  earlier  editions  of  this  work  an  improved  esophago- 
scope  has  been  invented,  which,  very  cautiously  employed,  can 
aid  much  in  the  recognition  of  disease  in  the  esophagus,  with 
only  a  little  risk  to  the  parts. 

Needless  instrumentation,  like  needless  surgery,  it  seems 
scarcely  necessary  to  say,  should  be  avoided,  and  I  here 
describe  and  recommend  the  simplest  methods  which  will 
effect  the  object  in  view.  The  soft,  flexible  tube  is  indispensa- 
ble in  many  cases  for  testing  the  gastric  contents  as  well  as 
for  lavage,  and  patients  soon  learn  to  tolerate  this  when 
deftly  used,  but  they  are  not  always  so  easily  reconciled  to 
more  formidable  intragastric  apparatus. 


LECTURE  VI 

THE  AUTHOR'S  METHOD  OF  OUTLINING 
THE  STOMACH  AND  DETERMINING 
THE  STATE  OF  ITS  MOTOR  FUNCTION- 
OTHER  METHODS  OF  EXAMINING  THE 
VISCERA 

The  subjoined  extracts  from  a  paper  written  by  myself^ 
while  engaged  at  work  in  Professor  Ewald's  clinic  in  the 
Augusta  Hospital  in  Berlin,  during  the  year  1895,  explain 
further  the  reasons  for  seeking  to  acquire  exact  knowledge 
concerning  the  stomach  and  its  functions  by  the  simplest  and 
least  disturbing  methods,  and  also  describe  the  combination 
of  such  methods  which  I  have  found  entirely  satisfactory. 
Fifteen  years  of  experience  with  these  methods  have 
confirmed  the  opinions  then  expressed.  With  the  exception  of 
the  soft  rubber  tube  recjuired  to  perform  lavage  in  cases  of 
stubborn  gastric  catarrh  or  dilatation  and  to  extract  the  gas- 
tric contents  for  the  purpose  of  analysis,  I  do  not  advise  phy- 
sicians in  general  practice  as  a  rule  to  employ  instruments 
within  the  stomach.  Those  of  you,  however,  who  have  not 
acquired  sufficient  expertness  in  percussion  and  its  various 
modifications  may  find  an  advantage  in  other  methods,  and  in 
the  cases  of  patients  who  present  none  of  the  symptoms  of 
ulcer  or  cancer  and  swallow  the  soft  tube  without  difficulty, 
may  safely  venture  upon  introducing  either  the  gastrodiaphane 
or  gyromele  to  clear  up  a  doubtful  diagnosis.  Under  similar 
conditions  and  restrictions  only  do  I  advise  you  to  use  for  the 
treatment  of  obstinate  cases  of  gastralgia,  deficient  gastric 
motility,  or  other  appropriate  cases,  the  method  of  intragas- 

"^Med.  News,  January  18,  i8g6,  and  Berh'ner  kli'n.   Wochenschr.,  1896, 
No.  43. 

90 


METHOD    OF    OUTLINING    THE    STOMACH  9I 

trie  electrization  for  which  special  electrodes  have  been 
devised  by  Stockton,  Ewald,  Einhorn,  myself,  and  others. 
With  the  same  cjualification,  you  may  also  find  it  safe  and  help- 
ful at  times  to  employ  an  intragastric  spray  apparatus.  But 
this  will  be  discussed  under  the  head  of  treatment  later  on. 
Here  follow  the  extracts  from  the  paper  above  referred  to : 

The  Use  of  a  Stomach  Tube  Sometimes  Impracticable 

"  There  are  many  cases  of  gastric  disease  in  which,  for  one 
reason  or  another,  we  cannot  employ  even  the  soft  tube,  and 
still  less  the  sound,  or  any  of  its  ingenious  modifications  and 
amplifications. 

"  Besides  the  contra-indications,  we  are  obliged  to  take  into 
account  the  foolish  dread  which  many  nervous  patients  have 
of  this  trifling  procedure  (the  introduction  of  the  stomach  tube) 
amounting  sometimes  to  an  insuperable  obstacle. 

"  In  order  to  reach  as  accurate  a  diagnosis  as  possible  in 
such  cases,  I  have  been  obliged  to  make  the  most  of  the  various 
methods  which  do  not  include  the  employment  of  any  instru- 
ment inside  the  stomach.  Trusting  that  the  mode  of  system- 
atizing such  methods  which  have  proved  useful  in  my  own 
work  may  be  helpful  to  others,  I  venture  to  submit  a  descrip- 
tion of  it.  .  ." 

A  Combination  of  External  Methods. — "  We  pass  on  to 
a  study  of  clapotement  (eliciting  a  splashing  sound  by  tapping 
with  the  fingers)  and  percussion.  It  is  to  the  value  of  the  com- 
bined employment  of  these  two  procedures,  according  to  a 
certain  order,  that  I  desire  to  call  attention  especially.  Both 
are  separately  well  described  in  the  works  of  Ewald, ^  Boas," 
and  other  standard  treatises  on  diseases  of  the  stomach, 
and  during  recent  years  there  have  been  numerous  contri- 
butions to  current  medical  literature  on  abdominal  per- 
cussion.    The  most  notable  of  these  is  a  paper  by  Dehio,^ 

i"Diseasesof  the  Stomach, "by  Prof.  C.  A.  Ewald,  M.  D.,  New  York,  1893. 

^"Diagnostik  u.  Ther.  der  Magenkrankheiten,"  by  Dr.  E.  Boas,  1894. 

'"Zur  ph^'sikalischen  Diagnostik  der  mechanischen  Insufficienz  des 
Magens,"  by  Dr.  Dehio.  Separat  Abdruck  aus'  den  Verhandlungen  des 
Congresses  f.  Innere  Medicin. 


92  METHODS    OF    EXAMINATION 

ill  which  he  gives  directions  for  percussing  with  the  patient 
lying  on  the  back,  as  well  as  standing,  after  drinking  various 
portions  of  water.  He  states  that  the  normal  empty  stomach 
is  entirely  within  the  thorax,  and  not  accessible  to  percussion, 
but  that  the  drinking  of  one-quarter  of  a  liter  of  water  pro- 
duces in  the  erect  position  a  dull  area,  which  extends  ii^ 
cm.  below  the  lower  end  of  the  corpus  sterni;  then  by  drinking 
the  same  quantity  a  second  time,  the  dullness  is  extended  2.7 
cm.  further  downward,  and  so  on,  until,  after  the  person  has 
taken  a  whole  liter,  he  finds  in  the  majority  of  cases  the  lower 
border  of  stomach  dullness  a  few  centimeters  above  the  level 
of  the  umbilicus.  He  points  out  also  that  from  the  different 
degrees  of  distensibility  thus  indicated  we  may  infer  much  as 
to  the  motility  of  the  stomach. 

"  On  the  other  hand,  Jaschtschenko,^  at  about  the  same 
time,  took  quite  the  opposite  view  of  the  matter.  He 
sharply  criticizes  Traube,  whose  conclusions  were  similar  to 
those  of  Dehio  above  cited,  and  declares  that  the  empty  stom- 
ach is  percussible,  and  that  filling  it  gradually  with  water 
causes  an  extension  of  the  dullness  upward,  but  not  downward. 
Neither  of  these  two  writers  makes  any  mention  of  clapote- 
ment. 

"  Obrastrow,-  of  Kiel,  writing  on  this  subject  in  1888 
an  elaborate  and  valuable  paper  which  I  had  not  seen  till  the 
present  article  had  been  nearly  finished,  gave  a  full  exposition 
of  clapotement,  but  had  not  at  that  time  as  much  faith  in  the 
accuracy  of  the  information  to  be  obtained  by  a  delicate  per- 
cussion as  he  has  evidently  since  accjuired,  judging  by  an  able 
contribution  which  has  just  appeared  from  his  pen.^ 

"  Certain  it  is  that  even  the  normally  small  healthy  stom- 
ach under  usual  conditions,  when  empty  as  well  as  full,  pre- 

'  "  Die  Grenzen  des  Magens  und  des  Darmcanals,"  by  Dr.  P.  Jascht- 
schenko,  Si.  Petersburger  iiied.   Woch.,  1888,  No.  29. 

' "  Zur  phys.  Untersuchung  des  Magens  und  Darms,"  von  Dr.  Obrastrow, 
Deutsches  Archiv.f.  kltnische  Mediciti,  December  7,  1888. 

^ "  Ueber  die  phys.  Untersuchung  des  Darms,"  von  Dr.  Obrastrow, 
Archiv.f.   Verdaunngs  Kraiikhciten,  1895,  B.  i.,  Heft  3. 


METHOD    OF    OUTLINING    THE    STOMACH  93 

sents  a  portion  of  its  anterior  surface  in  contact  with  the  front 
wall  of  the  thorax,  and  to  a  small  extent  with  the  front  wall 
of  the  abdomen  below  the  ribs;  and  except  in  conditions  of 
marked  obesity  it  is  not  generally  very  difficult  to  determine 
both  the  upper  and  lower  borders  of  that  portion  in  contact. 
But  stomachs  which  are  thus  almost  entirely  covered  by  the 
ribs  are  rare,  at  least  in  civilized  communities,  and  physicians 
are  seldom  called  upon  to  prescribe  for  them. 

"  Physicians  are  most  interested  in  abnormal  stomachs, 
which  nearly  always  extend  far  enough  below  the  ribs  to 
afford  us  the  opportunity  of  testing  their  condition  by  all  the 
usual  methods  of  physical  exploration. 

"  My  own  experience  has  convinced  me  that  stomachs,  like 
noses,  may  vary  considerably  in  size  and  yet  be  within  normal 
limits,  but  that  when  they  extend  in  the  empty  condition  much 
lower  than  a  point  midway  between  the  sternum  and  umbilicus, 
they  are  generally  pathologic.  That  experience  includes  the 
examination  of  about  300  persons  by  the  methods  now  under 
consideration ;  225  of  these  were  examined  in  the  course 
of  my  practice  in  Atlantic  City,  and  the  remainder  in  the 
Polyclinic  of  the  Augusta  Hospital  in  Berlin  during  the 
present  winter,  through  the  courtesy  of  Professor  Ewald  and 
his  chief  assistant,  Dr.  L.  Kuttner.  By  the  kindness  also  of 
Dr.  Oesterreicher,  pathologist  at  the  same  hospital,  I  have 
been  permitted  to  witness  numerous  autopsies  in  the  cases  of 
persons  who  had  had  various  forms  of  gastric  disease,  as 
well  as  a  few  whose  stomachs  were  normal  as  to  their  size  and 
position." 

Experiments  Carried  Out  by  the  Author  in  Ewald's 
Clinic, — "  In  a  number  of  the  cases  in  Ewald's  clinic,  in  which 
by  external  examination  I  had  diagnosticated  and  designated 
by  chalk  lines  on  the  abdomen  gross  departures  from  the  nor- 
mal in  the  way  of  displacements,  dilatation,  or  both,  the 
stomach  was  afterward  inflated  with  air  and  in  some  in- 
stances illuminated  by  the  electric  lamp  from  within,  with  a 
substantial  verification  of  the  results  previously  obtained. 


94 


METHODS    OF    EXAMINATION 


"  Experiments  were  made  by  me  in  a  series  of  six  cases  of 
gastrectasis  in  Ewald's  clinic  with  a  view  of  ascertaining 
whether  by  clapotement  and  percussion  together  it  is  possible 
to  determine  positively  when  the  stomach  has  emptied  itself. 
The  patients  reported  in  the  morning,  fasting.  In  each  of  these 
cases  when  the  splash  was  obtainable  and  percussion  in  the 


4^^ 

'■"m 

1 

/ 

/ 

\    |3 

l^-'--' 

V 

>  JH 

Ik 

Fig.  17: — Outlines  of  gastric  tympany  on  percussion  in  a  case  of  displace- 
ment and  dilatation  of  the  stomach. 

erect  position  demonstrated  dullness  in  the  lower  segment  of 
the  stomach,  I  was  able  afterward  by  means  of  the  tube  to 
bring  up  a  considerable  quantity  of  the  undigested  remnants 
of  a  previous  meal.  Then  after  carefully  emptying  the  stom- 
ach by  aspiration  the  former  tests  were  again  employed,  and 
this  time  with  negative  results. 

"  Tn  a  number  of  other  (doubtful)  cases  that  were  required 
to  present  themselves  in  the  morning  fasting,  the  presence  of 
fluid  in  the  stomach  was  suspected,  and  to  determine  the  ques- 
tion  I    practiced  clapotement   and   percussion,   but   failed   to 


METHOD    OF    OUTLINING    THE    STOMACH  95 

obtain  a  splash  or  to  detect  dullness  over  the  lower  part  of  the 
gastric  area  in  the  erect  position.  The  tube  was  then  used,  but 
nothing  obtained  except  three  or  four  grams  of  a  pale,  thin 
solution,  consisting  mostly  of  saliva. 

"  In  this  simple  manner,  therefore,  we  may  test  the  motil- 
ity of  any  given  stomach  frec|uently,  at  various  intervals  after 
various  kinds  of  meals,  with  very  little  difficulty  or  inconve- 
nience to  the  patient,  especially  after  the  boundaries  have  once 
been  accurately  determined. 

"  Numerous  experiments  have  also  been  made  by  me  to 
determine  whether  the  stomach  fills  upwards  or  sinks  lower 
after  the  taking  of  food  or  drink  in  successive  portions.  The 
results  have  been  somewhat  various,  as  might  be  expected, 
according  to  the  muscular  energy  of  the  stomach  tested.  In 
the  cases  of  gastrectasis  and  all  cases  of  weak  motility,  there 
has  been  a  depression  of  the  lower  border  after  each  glass  of 
water  except  when  it  was  already  at  the  lowest  point  attainable, 
and  then  there  was  a  demonstrable  widening  of  the  organ  on 
either  side.  Since  beginning  this  particular  investigation,  I 
have,  unfortunately,  not  been  able  to  find  many  normal  stom- 
achs, but  the  few  presumably  healthy  ones  examined  filled 
upw^ard,  without  the  lower  border  as  a  rule  showing  any 
noticeable  depression  after  drinking  several  successive  glasses 
of  water,  thus  confirming  the  observation  of  Jaschtschenko 
rather  than  those  of  Dehio  and  Traube.  In  some  casQS,  hov/- 
ever,  in  which  there  were  no  other  signs  of  weakness,  the  area 
of  dullness'  increased  both  upward  and  downward  after 
drinking. 

"  It  is  best  to  examine  the  patient  at  a  time  when  the  stom- 
ach should  be  entirely  empty — that  is,  in  the  morning  fasting,  or 
six  hours  at  least  after  the  last  meal.  But  this  is  not  always 
practicable,  and  after  a  light  breakfast  or  a  very  moderate 
luncheon  a  healthy  stomach  will  usually  be  found  by  the  tests 
of  clapotement  and  percussion  to  have  voided  its  contents  into 
the  intestines  at  the  end  of  two  hours.  Even  when  these  tests 
show  that  gastric  digestion  is  still  incomplete  we  may  in  many 


96  METHODS   OF   EXAMINATION 

cases,  nevertheless,  satisfy  ourselves  with  sufficient  accuracy  as 
to  the  size,  position,  and  motility  of  the  organ;  but  in  cases  of 
difficulty  or  obscurity  it  is  safest  to  examine  the  second  time 
under  -the  best  possible  conditions. 

"  If  upon  examining  a  patient  six  hours  at  least  after  his 
last  meal  we  obtain  the  splash  by  clapotement,  we  can  infer 
deficient  motility.  Noting  at  the  same  time  the  lowest  point 
where  the  splash  can  be  distinctly  heard,  we  may  infer,  as  a 
rule,  that  the  lower  boundary  extends  at  least  to  about  that 
level. 

"  We  should  then  percuss  the  abdomen  with  the  patient  in 
various  positions  to  verify  the  results  of  clapotement  and  map 
out  the  boundaries. 

"  If  no  splash  should  be  obtained,  before  proceeding  to  ad- 
minister w^ater  it  is  well  to  percuss  with  the  patient  first 
recumbent,  and  afterward,  in  the  erect  position,  to  determine 
the  apparent  stomach  boundaries  while  the  viscus  is  still  empty. 
Note  these  mentally  or  mark  them  on  the  body. 

"  Then  have  the  patient  drink  one-eighth  to  one-quarter 
liter  of  water,  and  try  again  to  obtain  the  splash.  If  it  is 
obtained  distinctly  after  the  smaller  amount  of  water  men- 
tioned, it  raises  a  question  as  to  the  motility,  and  will  also 
show  where  to  percuss  with  especial  care  and  delicacy  for  the 
lower  border. 

"For  the  adept  in  percussion  the  fingers  may  suffice  to 
bring  out  the  finer  differences  in  tone,  but  with  a  good  per- 
cussor  and  pleximeter  the  task  is  greatly  simplified." 

A  New  Pleximeter. — "  The  cut  of  a  new  pleximeter  devised 
by  myself  will  be  found  below.  It  is  wholly  made  of  rubber 
of  medium  hardness  and  is  very  easily  carried  in  the  pocket. 
The  smaller  end  serves  ordinarily  as  the  handle,  but  in  map- 
ping out  spaces  very  accurately  or  in  percussing  in  narrow 
spaces,  as  between  the  ribs  or  over  the  clavicle,  especially  in 
children,  it  is  better  to  reverse  the  ends  and  percuss  over  the 
smaller  part.      (See  Figure  No.  18.) 

"  Any  one  of  the  rubber-tipped  percussors  usually  found  in 


METHOD     OF     OUTLINING    THE    STOMACH  9/ 

the    instrument-stores    can    be    used    satisfactorily    with    this 
pleximeter." 

Mapping  out  the  Boundary, — "  Having  ah'eady  made  out 
the  apparent  boundaries  with  the  stomach  empty,  we  percuss 
again  with  it  partl}^  filled  while  the  patient  stands,  or,  in  the 
case  of  persons  who  are  in  bed  or  very  weak,  sitting  upright 


Fig.  i8. — Reed's  Pleximeter. 

will  usually  suffice  to  bring  the  fluid  contents  in  contact  with 
the  front  wall  of  the  abdomen  and  thus  develop  a  zonp  of 
dullness.  In  going  over  a  new  case  in  this  way  it  is  best  to 
give  one  glass  of  water  at  a  time,  when,  if  the  stomach  is 
atonic,  the  area  of  dullness  usually  extends  downward  with 
each  successive  glass;  but  if  entirely  strong,  it  extends  upward 
only  or  mainly. 

"  One  can  begin  either  above  or  below,  and  should  then 
percuss  carefully  in  the  median,  left  parasternal,  and  mam- 
millary  lines  from  the  level  of  the  nipple  to  the  pubes  in  any 
doubtful  case.  Having  determined  the  highest  and  lowest 
points  of  the  anterior  thoracic  and  abdominal  surface  with 
v\diich  the  stomach  is  in  contact,  we  should  percuss  perpendic- 
ularly across  the  oblique  curved  line  joining  these  points  and 
forming  the  left  lateral  boundary  of  this  epigastric  area.  Then 
the  right  lateral  boundarv  separating  the  stomach  from  the 
ascending  colon  should  be  made  out  in  like  manner.  With  the 
patient  erect  and  the  stomach  well  filled,  this  is  usually  a  simple 
matter,  the  ascending  and  descending  colons  and  their  flexures 
nearly  always  emitting  a  more  or  less  tympanitic  note,  even 
when  partly  filled.  If  the  precaution  has  been  taken  to  have 
the  colon  previously  emptied,  the  contrast  with  the  dull  note 
over  the  full  stomach  will  be,  of  course,  still  more  marked. 


98  METHODS   OF   EXAMINATION 

Having  the  patient  lie  first  on  one  side  and  then  on  the  other 
during  the  percussion  may  help  to  clear  up  a  doubtful  question. 
Filling  the  colon  with  air  b}-  the  double-bulb  rubber  syringe 
in  the  usual  manner  will  emphasize  strongly  the  contrast  w^ith 
the  dull  stomach-area  in  the  erect  position,  and  filling  the  colon 
with  tepid  water  while  the  patient  is  recumbent  reverses  the 
contrast  in  a  very  striking  manner,  though  this  is  not  a  feasible 
undertaking  with  all  patients,  since  some  cannot  retain  the 
liquid  long  enough. 

"  The  determination  of  the  upper  border  or  stomach-lung 
boundary  is  the  most  difficult  part  of  the  procedure.  Usually, 
however,  by  trying  alternately  light  and  strong  percussion,  there 
will  be  obtained  a  marked  difference  in  the  two  qualities  of  the 
resonant  tone,  that  over  the  stomach  being  more  tympanitic. 
Still  it  recjuires  much  skill  to  make  this  out  quickly  and 
positively.  Occasionally,  in  exceptional  cases  wdiere  the  stom- 
ach contains  very  little  gas,  we  may  fail  at  one  examina- 
tion and  succeed  readily  at  a  second  one.  This  line  is  some- 
times more  easily  determined  after  a  meal,  since  then  such 
gases  as  are  present  are  forced  to  the  upper  part  and  produce 
more  tympany.  One  needs  to  bear  in  mind  such  possible  dis- 
turbing factors  as'  a  greatly  enlarged  spleen  or  enlarged  left 
lobe  of  the  liver;  also  left-sided  pleurisy  filling  up  the  half- 
moon-shaped  space  of  Traube  with  exudation." 

In  some  cases  in  which  there  is  only  a  slight  or  small  degree 
of  motor  insufficiency,  especially  in  obese  persons,  it  is  diffi- 
cult or  impossible  to  obtain  a  splashing  sound  by  the  usual 
manipulations  alone.  By  causing  such  patients  to  contract  and 
relax  alternately  while  the  physician  makes  the  tapping 
movements  with  his  finger-tips,  the  splashing  may  often  be 
elicited. 

The  Determination  of  the  Gastric  Motor-Power. — The 
above-described  combination  of  external  methods  will  enable 
you  to  map  out  the  boundaries  of  the  viscera  in  nearly  all 
cases  without  even  introducing  a  tube  into  the  stomach,  and 
having  done  this,  to  ascertain  at  any  time  when  the  stomach  is 


METHOD    OF    OUTLINING    THE    STOMACH  99 

empty  or  contains  a  large  or  small  amount  of  fluid.  It  is 
then  manifestly  going  only  a  step  further  to  determine  the 
relative  motor  power  of  the  latter  organ.  The  presence, 
extent,  and  loudness  of  a  splash  afford  valuable  evidence  as  to 
the  motility,  for  in  a  normal  stomach  there  is  no  splash,  and 
the  weaker  the  walls  the  greater  the  splash,  but  with  the  data 
above  mentioned  you  can  determine  the  motor  power  as  ab- 
solutely as  by  the  Leube  method  of  extracting  the  contents 
with  the  tube  at  various  times  after  a  definite  kind  of  meal. 
For,  knowing  where  the  lower  boundary  of  the  stomach  is, 
with  this  knowledge,  and  the  aid  of  percussion  and  the  splash, 
you  can  decide  with  almost  as  much  exactness  as  with  the 
tube  when  the  viscus  has  emptied  itself. 

The  time  required  by  the  stomach  to  empty  itself  determines 
its  motility.  Three  hours  after  the  Ewald  test  breakfast,  con- 
sisting of  a  dry  roll  and  ten  ounces  of  water,  the  gastric  coi> 
tents  should  have  passed  on  into  the  bowel;  and  seven  hours 
after  the  test  dinner  none  of  it  should  be  left  in  the  stomach. 
A  longer  retention  of  either  meal  signifies  a  weakened  motility, 
or  else  obstruction  at  or  near  the  pylorus. 

INFLATION   OF   STOMACH   AND    COLON,   ETC. 

The  principal  addition  to  the  above-described  methods  as 
originally  prescribed  by  me  is  preliminary  inflation,  of  the 
stomach  with  either  air  forced  in  through  a  tube,  or  carbonic 
acid  gas  (CO2)  formed  within  the  viscus  by  sodium  bicarbon- 
ate and  an  acid.  Formerly  I  inflated  by  pumping  in  air, 
but  as  this  required  an  extra  introduction  of  the  tube,  and 
I  found  long  ago  that  moderate  inflation  with  COo,  when 
properly  managed,  involved  no  danger,  while  it  was  of  very 
decided  assistance  in  facilitating  the  process  of  mapping  out 
the  boundaries,  I  have  since  employed  it  in  nearly  all  my 
important  cases  after  roughly  determining  the  upper  and 
lower  limits  without  it.  The  patient  is  asked  to  drink  a 
solution  of  half  to  a  level  teaspoonful  of  sodium  bicarbonate 


lOO  METHODS    OF    EXAMINATION 

in  a  goblet  of  water/  Then,  if  becanse  of  there  being  little 
or  no  free  acid  in  the  stomach,  insufficient  inflation  results, 
8  to  12  drops  of  strong  chemically  pure  hydrochloric  acid, 
according  to  the  amount  of  soda  used,  may  be  dissolved  in 
another  glass  of  water  and  taken  by  the  patient.  After  a 
momentary  kneading  of  the  epigastrium  the  two  chemicals 
combine  and  the  stomach  is  inflated  with  the  disengaged  COo, 
so  that  a  tympanitic  note  is  produced  by  even  very  light  per- 
cussion anywhere  over  it.  This  procedure  has  been  employed 
by  me  thousands  of  times  without  any  unpleasant  results,  but 
is  likely  to  distend  atonic  stomachs  somewhat,  increasing  their 
apparent  size,  and  it  is  therefore  desirable  to  percuss  and 
try  to  elicit  the  splash  both  before  and  after  inflation. 

It  will  be  noticed  that  I  do  not  follow  the  directions  laid 
down  by  most  other  authors  as  to  the  choice  of  an  acid  to 
form  with  soda  the  COo.  These  recommend  tartaric  acid, 
which  is  effective  but  often  purges,  and  this  is  not  always 
desirable. 

Summary  of  the  Author's  Method. — Percuss  and  try  to 
obtain  the  splashing  sound  with  the  patient  first  recumbent  and 
then  in  the  erect  posture;  also  before  and  after  administering 
successive  glasses  of  water. 

If  a  splashing  sound  can  be  obtained,  the  lowest  point  where 
it  can  be  heard  will  indicate  approximately  the  position  of  the 
greater  curvature.  When  there  is  doubt  or  difficulty  in  dis- 
tinguishing the  percussion  notes  obtained  over  it  and  the  ad- 
joining structures,  inflate  the  stomach  and  then  percuss 
again. 

Very  delicate  and  precise  results  can  be  obtained  by  ausculta- 
tory friction,  with  the  help  of  a  good  phonendoscope  or  bin- 
aural stethoscope.  In  auscultatory  percussion,  the  ear  pieces 
of  the  instrument  being  in  their  places,  the  other  end  is  held 
by  an  assistant  or  by  the  patient  in  the  desired  locations,  while 

'  The  amounts  of  soda  here  advised  are  much  larger  than  those  neces- 
sary to  neutralize  the  specified  quantities  of  HCl  (which  would  be  i  gram 
HCl  to  .86  grams  HNaCOs),  but  there  is  usually  some  acid  in  the  stomach, 
and  in  any  case  an  excess  of  soda  is  safe. 


METHOD    OF     OUTLINING    THE     STOMACH  lOI 

the  examiner  percusses  lightly  in  various  directions  from  it. 
The  differences  in  pitch  and  cjuality  of  sound  are  thus  greatly 
exaggerated. 

In  auscultatory  friction  the  instrument  is  held  in  like  man- 
ner while  the  finger  tip,  pencil,  or  other  similar  object  is  rubbed 
over  the  skin.  The  sound  thus  produced  is  heard  distinctly  so 
long  as  the  rubbing  is  made  over  the  hollow  organ  over  which 
the  stethoscope  is  placed  and  not  more  than  two  or  three  inches 
away  from  it,  while  upon  crossing  the  boundary  to  another 
organ,  even  an  inch  away  from  the  stethoscope,  it  is  no  longer 
heard. 

Compare  the  findings  from  these  various  percussions  under 
the  following  different  conditions : 

I.  The  stomach  and  transverse  colon  being  both  empty 
except  gas,  with  the  patient  recumbent,  tympanitic  notes, 
nearly  always  different  in  pitch  and  Cjuality,  will  be  heard  over 
these  two  viscera,  while  occasionally  a  still  higher  pitched 
sound  may  be  heard  lower  down  over  the  coils  of  the  small 
intestine.  The  boundary  above,  between  stomach  and  heart, 
can  then  be  generally  made  out  except  in  fleshy  persons  (who 
are  not  often  sufferers  from  serious  gastric  disease),  or  when 
there  is  very  little  gas  in  the  stomach.  In  these  cases  inflation 
will  be  necessary,  and  this  will  also  greatly  intensify  the 
difference  between  the  percussion  notes  over  the  stomach  and 
colon. 

II.  With  the  same  conditions  except  that  the  patient  is 
standing  the  results  should  be  much  the  same,  though  since  the 
gas  rises  to  the  highest  part  of  the  stomach,  there  is  often  a 
greater  tympany  there.  This  facilitates  the  determination  of 
the  boundary  between  the  stomach  and  heart  and  between 
the  stomach  and  lungs.  If  there  should  be  even  a  very  mod- 
erate amount  of  fluid  remaining  in  the  stomach,  it  will  give  a 
narrow  zone  of  dullness  at  its  lowest  part. 

III.  With  the  colon  empty  and  the  stomach  containing  two 
glasses  of  water,  you  will  have  the  same  findings  as  before 
while  the  patient  is  recumbent,  except  that  the  tympany  over. 


102  METHODS    OF    EXAMINATION 

the  stomach  should  be  more  marked  even  without  inflation, 
but  upon  the  standing"  position  being  assumed,  the  condition 
is  iinmediately  and  strikingly  changed.  There  is  now  a  de- 
cidef\  zone  of  dullness  across  the  lower  portion  of  the  region 
over  the  stomach,  while  the  note  over  the  intestines  remains 
tympanitic,  as  before. 

After  finishing  percussion  further  useful  information  may 
be  gained  by  trying  clapotement  again  with  the  two  glasses 
of  water  in  the  stomach.  While  the  patient  is  lying  on  the 
back,  as  before  described,  make  repeated  tappings  with  the 
fingers  over  different  parts  of  the  epigastric  region.  If  a  loud 
splash  is  easily  obtained  over  a  wide  area,  the  stomach  walls 
are  atonic — its  motility  bad.  If,  in  addition  to  much  splash- 
ing in  it,  the  organ  has  been  found  to  be  enlarged,  there  is 
gastric  dilatation,  which  is  more  or  less  extensive  according 
to  the  extent  of  the  area  over  which  the  splash  can  be  pro- 
duced. The  use  of  the  phonendoscope  will  enable  you  the 
more  readily  to  determine  this  area,  though  you  may  some- 
times be  misled  by  it,  since  a  splashing  sound  may  often  be 
heard  through  it  at  some  little  distance  from  the  place  where 
it  is  actually  produced.  Clapotement  is  less  reliable  than 
percussion  for  the  determination  of  boundaries,  but  the  two 
methods  may  both  be  employed  when  accuracy  is  desired,  so 
as  to  have  one  confirm  or  correct  the  other. 

Radiographs  of  the  Viscera. — In  the  case  of  a  patient  with 
thin  abdominal  walls,  a  powerful  x-ray  apparatus  in  the 
hands  of  an  expert  will  often  produce  a  radiograph  in  which 
the  outlines  of  the  stomach  can  be  clearly  made  out,  provided 
a  solution  containing  one  dram  of  bismuth  subcarbonate  has 
been  administered  twice  or  thrice  a  day,  some  time  before 
meals,  for  two  days  preceding.  When  Turck's  gj-Tomele 
has  been  previously  introduced  into  the  stomach  the  result 
can  be  made  still  more  satisfactory.  The  metal  cable  of  this, 
inclosed  within  a  tube,  makes  a  sharp  contrast  with  the 
surrounding  part  of  the  picture,  and  nearly  always  the  gyro- 
mele  may  be  depended  upon  to  follow,  and  thus  outline  dis- 
tinctly, the  greater  curvature  of  the  stomach.     By  repeated 


METHOD   OF    OUTLINING    THE    STOMACH  IO3 

injections  of  a  sufficient  cjuantity  of  bismuth  or,  which  is 
safer,  magnetic  iron  oxide,  into  the  bowel  the  colon  may  be 
sufficiently  coated  with  this  material  to  assist  in  obtaining 
a  fairly  good  radiograph  of  that  viscus :  but  as  in  the  case 
of  the  stomach  the  previous  introduction  of  an  elastic  metal 
sound  will  give  more  definite  results  relative  to  the  course 
of  the  colon,  even  if  it  cannot  show  its  size  or  caliber.  See 
p.  88  as  to  the  dangers  of  bismuth. 

In  a  patient  with  a  not  too  sensitive  intestinal  mucous 
membrane,  you  may  determine  the  position  of  the  colon  in 
its  various  parts  by  filling  it  from  below  with  a  warm  weak 
solution  of  salt  (5  i  to  the  cjuart),  while  he  lies  on  the  back 
or  left  side  with  the  hips  elevated.  By  injecting  enough  of 
the  salt  solution  you  may  be  able  to  obtain  a  dull  percussion 
note,  or  by  auscultation  with  the  stethoscope  or  phonendo- 
scope  while  you  tap  over  the  different  parts,  you  may  hear 
gurgling  or  slight  splashing  sounds  over  the  course  of  the 
colon,  especially  if  it  be  dilated.  For  the  success  of  this 
procedure  it  is  necessary  that  the  stomach  should  be  wholly 
empty,  so  that  any  splashing  sound  could  arise  nowhere 
except  in  the  colon  or  cecum. 

The  Pottenger  Method  of  Outlining  Organs. — Dr.  F.  M. 
Pottenger  of  Los  Angeles  has  described  a  remarkable  refine- 
ment of  examination  which  he  calls  "  Light  Touch  Palpa- 
tion." By  a  touch  so  light  that  it  barely  indents  the  skin, 
the  various  solid  viscera,  such  as  the  heart  and  liver,  and 
in  some  cases  the  stomach,  following  a  meat  can  be  accu- 
rately outlined.  It  is  a  very  simple  method  and  depends 
upon  the  fact  that  organs  and  parts  of  organs  differing  in 
density,  offer  different  degrees  of  resistance  to  the  palpating 
finger.  The  doctor's  own  description  of  it  should  be  read 
in  full.^  I  can  personally  vouch  for  the  value  of  this  method. 
Of  late  (1910)  I  have  been  employing  it  as  the  preferable 
procedure  in  beginning  an  examination  for  determining  espe- 
cially the  lateral  and  lower  boundaries  of  the  stomach.  These 
can  usually  be  made  out  in  this  way  in  a  minute  or  two,  and 

^So.  Cal.  Practitioner,  Dec.  '09. 


I04  METHODS    OF    EXAMINATION 

the  findings  are  rarely  changed  by  the  time-consuming  method 
of  percussion  after  inflation,  etc.,  already  described.  The 
colon  can  sometimes  be  outlined  in  the  same  way  though  not 
so  certainly  unless  full  of  hard  feces. 

V 

CAPACITY  AND  MOTOR  POWER  OF  THE  STOMACH 
Tests  of  the  Capacity  of  the  Stomach. — Among  these  there 
are  some  involving  difficult  mathematical  calculations  which 
require  time  and  trouble  out  of  proportion  to  the  value  of  the 
information  thus  obtained.  When  the  boundaries  of  the 
stomach  are  accurately  determined,  its  capacity  can  usually 
be  inferred  with  sufficient  exactness.  One  method  of  attempt- 
ing to  ascertain  the  capacity  of  the  stomach,  I  mention  here 
only  to  condemn.  It  is  rec|uiring  the  patient  to  drink  as  much 
water  as  possible,  keeping  a  strict  account  of  the  arhount  taken 
and  inferring  thence  what  the  capacity  of  the  viscus  is.  This 
is  not  only  an  injurious  method  which  by  frecjuent  practice 
could  easily  overdistend  and  dilate  the  stomach,  but  is  also 
a  nearly  useless  one,  the  amount  of  fluid  which  any  person 
can  be  induced  to  drink  at  one  time  depending  quite  as  much 
upon  the  tolerance  of  the  gastric  mucous  membrane  and  the 
amount  of  discomfort  which  a  patient  is  willing  to  bear,  as 
upon  the  capacity  of  the  stomach.  Moreover,  another  element 
of  uncertainty  in  such  a  test  is  the  patulousness  of  the  pylorus. 
In  some  persons  the  pylorus  remains  tightly  closed  during 
the  whole  time  of  the  experiment,  while  in  others  the  normal 
rhythmic  opening  of  the  same  would  permit  of  the  escape 
of  a  considerable  part  of  the  fluid  ingested  during  the  time 
of  observation.  In  still  other  cases  the  pylorus  is  stiffened 
by  disease  in  such  a  way  that  it  is  continuously  open,  not 
being  capable  of  complete  closure,  and  in  such  caSes  a  large 
part  of  the  liquid  ingested  for  the  test  would  pass  out  during 
the  experiment. 

The  salol  test  of  gastric  motility  is  not  now  much  depended 
upon  by  the  best  authorities. 

Other  Methods  of  Testing  the  Motility  of  the  Stomach. — 
Dehio  has  a  patient  drink  one-fourth  of  a  liter  of  water  and 


METHOD    OF    OUTLINING    THE    STOMACH  IO5 

then  determines  by  percussion  the  position  of  the  greater 
curvature  of  the  stomach.  Then  in  succession  three  like 
cjuantities  of  water  are  given  and  the  position  of  the  greater 
curv^ature  is  determined  after  the  drinking  of  each  portion. 
When  the  motihty  is  normal,  the  stomach  does  not  distend 
downward  to  any  noteworthy  extent,  but  the  greater  the 
motor  insufficiency  the  lower  will  the  stomach  descend  after 
each  additional  glass  of  water.  This  is  a  method  of  value  and 
can  be  easily  applied  in  most  cases.  The  presence  of  a  loud 
splashing  heard  over  a  large  part  of  the  stomach  is  one  of 
the  surest  evidences  of  weak  motor  power  in  the  viscus. 

Carnot  ^  has  recently  recommended  a  simple  method  for 
determining  in  case  of  delayed  emptying  whether  or  not 
there  is  obstruction  at  or  near  the  pylorus.  After  the 
fasting  stomach  has  been  washed  out,  the  patient  drinks 
a  pint  of  water  and  stands  or  sits  upright  for  an  hour.  If 
the  delayed  emptying  has  been  due  to  atony  or  dilatation 
even  with  no  existing  obstruction,  much  of  the  water  would 
be  found  still  in  the  stomach  at  the  end  of  the  hour.  Then, 
on  another  morning  the  experiment  is  repeated  with  the 
patient  reclining  on  the  right  side  so  as  to  make  the  pylorus 
surely  the  most  dependent  part  and  enable  the  water  to  escape 
easily  by  gravity  provided  the  pylorus  be  patulous,  but  other- 
wise not.  If  now  the  stomach  has  emptied  itself  within  the 
hour  the  second  time  but  not  the  first  time,  there  is  no  stenosis 
at  or  near  the  outlet  and  atony  exists.  If  it  does  not  empty 
even  while  the  patient  lies  on  the  right  side,  the  pylorus  or 
possibly  ihe  small  intestine  is  obstructed. 

There  is,  however,  a  possible  exception.  In  a  case  of 
hyperchlorhydria  there  might  be  food  stagnation  from  pyloro- 
spasm  while  the  water  would  still  pass  out  in  the  normal  time. 

Another  method  is  to  introduce  the  tube  at  various  intervals 

after  some  definite  meal  has  been  eaten — for  example  at  five, 

six,  seven,  and  eight  hours  after  the  Leube  test  dinner — to 

ascertain  whether  any  fluid  is  then  in  the  stomach.     If  at  the 

'^Press,e  Medic  ale,  1909. 


I06  METHODS    OF    EXAMINATION 

end  of  fi\'e  hours  only  a  small  quantity  of  chyme  remains,  the 
motility  would  be  shown  to  be  good,  especially  if,  at  the 
end  of  six  hours,  the  stomach  should  be  found  to  be  com- 
pletely empty.  If  food  remains  should  be  found  at  longer 
intervals  after  such  a  meal,  they  would  indicate  the  probability 
of  muscular  insufhciency  or  deficient  motility  in  the  stomach, 
and  the  longer  the  time  after  the  meal  when  such  remains 
could  be  found  the  greater  would  be  the  muscular  insufficiency 
to  be  inferred ;  yet,  on  the  other  hand,  a  deficient  secretion 
causing  very  imperfect  digestion  can  also  delay  the  emptying 
of  the  stomach.  There  is  an  obvious  fallacy,  therefore,  in  this 
last  method  of  testing  the  motility,  and  it  really  renders  it 
untrustworthy  unless  a  careful  account  be  taken  at  the  same 
time  of  the  other  conditions  present.  At  least  two  other  condi- 
tions besides  the  strength  of  the  gastric  musculature  affect  the 
length  of  time  during  which  a  meal  remains  in  the  viscus. 
These  are  the  efficiency  of  the  digestive  glands  and  the  pro- 
portion of  acid  present,  not  to  speak  of  a  possible  mechanical 
obstruction  at  the  pylorus.  When  the  percentage  of  HCl  and 
pepsin  is  so  low  that  digestion  proceeds  very  slowly  and  an 
abnormally  long  time  elapses  before  the  coarser  particles  of 
the  food  are  dissolved,  the  emptying  of  the  stomach  may  be 
much  delayed,  especially  when  mastication  has  been  imperfect, 
since  the  pylorus  does  not  readily  open  to  permit  of  the  ex- 
pulsion of  bulky  particles  not  in  solution.  Again  when  the 
contents  of  the  stomach  are  abnormally  acid,  whether  from  an 
excessive  secretion  of  HCl  by  the  gastric  glands,  the  ingestion 
of  an  excessive  amount  of  acid  with  a  meal,  or  the  develop- 
ment even  of  very  large  amount  of  organic  acids  in  the 
stomach  from  fermentation  of  the  food,  there  is  frecjuently 
such  a  spasmodic  closure  of  the  pylorus  as  delays  very 
markedly  the  time  of  emptying ;  and  when  there  is  a  thickening 
of  the  structures  about  the  pylorus,  whether  from  h3^pertrophy 
of  the  muscle,  the  scar  of  a  healed  ulcer  or  a  malignant 
growth,  a  narrowing  of  the  outlet  results  with  consequent 
delay  in  the  expulsion  of  the  gastric  contents. 

The  chief  value,  then,  of  canwing  out  this  method  of  Leube, 


METHOD    OF    OUTLINING    THE    STOMACH  107 

which  has  been  considered  the  most  rehable  of  the  tests  for 
gastric  motihty,  is  that  thereby  you  may  learn  that  there  is, 
or  is  not,  present  some  decided  fault  in  the  stomach — either 
in  its  secretory  or  motor  functions  or  both.  When  by  this 
test  such  a  fault  is  discovered  to  exist,  it  becomes  your  duty 
to  search  further  and  ascertain  the  real  cause.  E.  g.,  when 
you  wash  out  six  hours  after  a  hearty  dinner  and  find  a  large 
quantity  of  semi-digested  food  with  a  very  offensive  odor 
suggestive  of  the  swill  barrel  on  a  hot  day,  you  can  infer  that 
the  gastric  secretion  is  deficient,  and  that  probably  the  motor 
power  is  so  also,  since  the  amount  of  fermentation  evident 
would  be  prima  facie  evidence  that  it  must  be  at  least  con- 
siderably below  normal.  On  the  other  hand  if  the  tube  readily 
brings  away  at  the  same  interval  after  a  generous  dinner  of 
meats  and  vegetables  a  large  amount  of  perfectly  digested 
fluid,  especially  if  it  has  little  odor,  but  tastes  very  sharply  acid, 
and  an  analysis  reveals  HCl  excess,  you  can  decide  that 
the  case  is  one  of  hyperchlorhydria  with  likely  a  spasm  of 
the  pylorus  delaying  the  emptying  of  the  stomach,  rather 
than  deficient  motor  power  in  the  gastric  walls.  But 
in  a  less  marked  case,  showing  a  small  amount  of  poorly 
digested  stomach  contents  at  the  end  of  seven  hours,  with  only 
a  moderate  deficiency  of  HCl  and  the  ferments  and  not  much 
evidence  of  fermentation,  the  diagnosis  as  to  the  gastric  mo- 
tility would  remain  in  doubt.  For  the  purpose  merely  of 
testing  the  gastric  motor  power,  the  simpler  methods  above 
described  are  manifestly  about  as  reliable  as  any. 


THE    EXAMINATION   OF    THE    SECRE- 
TORY FUNCTION  OF  THE  STOMACH 

LECTURE  VII 

INSTRUMENTS  USED    FOR   THE    EXTRAC- 
TION   OF   THE    STOMACH    CONTENTS 

How  to  Introduce  the  Tube  into  the  Stomach  with  the 
least  possible  Embarrassment  of  the  Patient. — For  diagnostic 
purposes  you  will  usually  introduce  the  familiar  soft,  flexible, 
rubber  tube  in  order  to  bring  up  a  sample  of  the  stomach  con- 
tents either  an  hour  after  the  Ewald  test  breakfast  of  bread 
and  tea  or  water,  or  two  to  four  hours  after  a  mixed  meal 
consisting  of  either  meat  or  eggs  and  a  more  generous  al- 
lowance of  carbohydrates,  as  will  be  found  explained  fully, 
further  on,  in  the  section  devoted  to  test  meals. 

It  is  customary  with  many  physicians  to  make  use  of  the 
tube  first  for  washing  out  the  stomach,  wdiich  is  usually  a 
somewhat  tedious  procedure  and  likely  to  be  a  trying  one  to 
the  novice.  Extracting  a  sample  of  the  stomach  contents,  on 
the  other  hand,  is  a  comparatively  simple  and  little  troublesome 
task  in  a  majority  of  cases  when  skillfullv  performed.  This 
is  especially  true  when  a  good  aspirator  is  deftly  used  and  the 
attempt  is  not  made  to  extract  all  of  the  stomach  contents,  as 
is  practiced  by  many  specialists  and  taught  in  nearly  all  treat- 
ises upon  the  subject  of  stomach  diseases.  Even  with  the 
best  intention  it  is  often  impossible  to  empty  completely  the 
stomach  with  the  tube,  some  ounces  of  fluid  nearly  always 
remaining;  and  even  if  practicable  it  is  not  often  desirable, 
particularly  with  a  new  patient.  The  knowledge  of  the  gastric 
motility  thus  obtained  is  often  inaccurate  and  misleading  and 

io8 


SECRETORY    FUNCTION    OF    THE    STOMACH  IO9 

at  all  events  could  be  obtained  in  other  ways  more  easily  and 
satisfactorily.  (See  preceding  lecture  on  "The  Author's 
Method  of  Outlining  the  Stomach  and  Determining  the  State 
of  its  Motor  Function.") 

To  empty  the  stomach  as  completely  as  possible  takes  much 
more  time  and  subjects  the  inexperienced  patient  to  decidedly 
more  annoyance  than  is  necessary.  But  in  patients  used  to 
the  tube  as  much  as  possible  should  be  extracted,  since  this 
may  secure  somewhat  greater  accuracy  in  the  chemical  find- 
in2:s.  _ ^ 


Fig.  19. — Flexible  stomach  tube  with  fenestrum  attached. 

Select  for  first  use  ordinarily  a  tube  not  too  large  (not  over 
a  No.  28  or  30,  French),  highly  polished,  of  medium  flexi- 
bility and  with  a  conical  end,  having  an  opening  directly  in 
the  end,  and  at  least  one  fenestrum  on  the  side,  about  three- 
quarters  of  an  inch  above.  It  should  have  in  it  also  some- 
where two  or  three  inches  of  glass  tubing  as  a  window.  You 
will  need  larger  tubes  when  extracting  the  stomach  contents 
in  cases  of  gastric  catarrh  or  of  food  stagnation;  also,  if  you 
should  wash  out  at  any  time  other  than  before  breakfast. 

As  a  lubricant  for  the  tube,  warm  water  answers  well  as  a 
rule,  though  olive  oil,  butter,  or  glycerine  is  often  used. 
Wetting  the  tube  in  ice  water  helps  usually  to  prevent  spasm 
of  the  glottis. 

Preparation  of  the  Patient. — It  is  best  to  prepare  the  new 


1  lO 


METHODS   OF   EXAMINATION 


patient  for  the  introduction  of  the  tube  l3y  a  feW  words  of 
prehminary  explanation.  If  he  has  not  been  frightened  con- 
cerning the  procedure  by  an  exaggerated  account  of  it  given  by 
some  fooHsh  friend,  the  difficulty  will  be  far  less  than  when 
such  a  prejudice  has  been  created  against  it.  The  less  said  be- 
forehand about  your  intention  to  take  up  the  stomach  contents 
the  better.  My  own  rule  is  to  ask  the  patient  to  eat  a  stale 
roll  and  drink  a  goblet  and  a  half  of  water  at  8.15 
a.  m.,  and  be  at  my  office  at,  say,  five  minutes  after  nine  with- 
out mentioning  for  what  purpose  such  a  light  meal  is  to  be 


Fig.  20. — Flexible  stomach  tube,  with  funnel  attached. 

taken.  Caution  is  given  not  to  take  any  other  food  or  drink, 
or  any  medicine,  that  morning  until  after  reaching  my  office. 
Then  when  the  patient  comes,  he  is  told  that  I  would  like  to 
have  a  few  spoonfuls  of  his  stomach  contents  and  that  he  will 
need  to  swallow  one  end  of  a  small  and  flexible  rubber  tube 
for  that  purpose.  No  display  of  the  tube  is  made  beforehand, 
and  every  effort  is  made  to  prevent  the  development  of  any 
excitement  or  fear.  Then  by  9.15,  one  hour  after  the  patient 
began  to  eat  his  test  breakfast,  all  should  be  in  readiness  for 
the  actual  extraction. 

Having  secured  then  the  proper  mental  state,  which  should 
be  as  nearly  as  possible  one  of  composure,  devoid  of  excite- 
ment  and   apprehension,   slip   around   the   patient   an   apron, 


SECRETORY     FUNCTION     OF     THE     STOMACH  III 

preferably  of  thin  rubber  cloth  and  large  enough  to  cover  the 
body  down  to  the  knees.  This  should  pass  outside  the  arms 
(so  as  to  prevent  the  hands  involuntarily  grabbing  the  tube 
at  a  critical  moment)  and  be  buttoned  or  tied  behind  the  back. 
Then  place  him  in  a  sitting  position,  in  a  good  light,  and  sit 
down  yourself  in  a  lower  chair  in  front,  but  a  little  to  his  right, 
so  that  if  he  should  chance  to  vomit,  you  would  not  be  in  the 
way.  Tell  him  now  to  open  his  mouth  widely,  hold  his  head 
bent  a  little  forward  (not  far  back,  as  most  patients  incline  to 
hold  it),  and  breathe  regularly  w^ith  unusual  deepness;  that  the 
only  reason,  as  a  rule,  why  some  persons  are  uncomfortable 
when  they  first  take  a  tube  is  that  their  respiration  is  em- 
barrassed as  a  result  of  a  reflex  irritation  from  the  nerves  of 
the  throat,  and  that  this  can  be  usually  avoided  by  breathing 
very  deeply.  Show  him  what  you  mean  by  taking  a  few 
strong  inspirations  yourself  and,  if  doubtful  of  him,  ask  him 
to  breathe  as  desired  for  a  few  moments  before  you  introduce 
the  tube. 

Introducing  the  Tube. — Then,  taking  hold  of  the  tube  as 
you  would  a  pen,  about  six  inches  from  the  stomach  end,  pass 
it  carefully  back  over  the  center  of  the  tongue  into  the  pharynx. 
Use  your  sight,  and  not  a  finger  of  the  other  hand,  to  guide 
the  end  of  the  tube  down  through  the  middle  of  the  pharynx 
into  the  esophagus.  The  moment  it  reaches  the  pharynx  the 
patient  must  be  induced  to  make  several  rapidly  repeated  swal- 
lowing movements,  which  will  facilitate  its  entrance  into  the 
esophagus,  down  which  it  will  glide  easily  with  the  gentlest 
pushing  on  your  part,  provided  the  patient  continues  breathing 
at  least  as  deeply  as  normal  and  makes  swallowing  motions 
between  times.  Even  without  the  swallowing  the  tube  can 
in  most  cases  be  easily  and  safely  pushed  on  into  the  stomach 
if  full  inspirations  are  kept  up. 

You  will  generally  have  difficulty  in  getting  a  tube  into  the 
stomachs  of  hard  drinkers  or  heavy  smokers,  and  will  often  fail 
altogether  with  them.  Very  nervous  or  hysterical  women 
are    also    troublesome    usually,    but    will    occasionally    sur- 


112  METHODS   OF   EXAMINATION 

prise  you  by  the  ease  with  which  they  swallow  the  little  instru- 
ment for  the  first  time ;  sometimes,  however,  one  with  extraor- 
dinarily heightened  reflexes  about  the  pharynx  and  very  weak 
will  'power  is  unable  to  resist  the  impulse  to  seize  and  pull 
out  the  tube  the  moment  it  enters  the  esophagus,  or  even 
when  it  has  already  passed  into  the  stomach  and  self-control 
for  a  second  or  two  longer  would  enable  a  sample  of  the  stom- 
ach contents  to  be  obtained  for  analysis.  In  such  cases  it  is 
indispensable  that  the  hands  be  either  well  pinioned  by  a  snug- 
fitting  apron  or  held  in  the  hands  of  an  attendant,  under  the 
guise  of  sympathetic  support. 

It  is  unusual  for  patients  to  complain  of  any  serious  nausea 
as  the  result  of  the  introduction  of  a  tube,  and  I  should  say 
that  not  more  than  one  in  twenty  is  excited  to  vomiting  by  it. 
The  annoyance  usually  is  from  embarrassed  respiration,  the 
patient  feeling  as  though  he  could  not  breathe.  There  is  ap- 
parently in  these  cases  a  real  obstruction  of  the  air  passages, 
a  result,  according  to  Vierordt,  of  a  spasm  of  the  glottis.  This 
can  generally  be  overcome  by  voluntarily  bringing  into  action 
the  auxiliary  respiratory  muscle?  and  making  rhythmical 
forced  inspirations.  This  relieves  in  a  double  way,  ( i )  by 
diverting  the  attention  of  the  patient  from  the  passage  of  the 
tube  and  thus  lessening  the  tendency  to  reflex  spasmodic 
action,  and  (2)  by  powerfully  expanding  the  lungs  so  as  to 
obtain  the  entrance  of  air  in  spite  of  the  contraction. 

Training  of  Irritable  Throats. — You  will  see  cases  occasion- 
ally in  which  efiforts  at  deep  inspiration  will  fail  and  the  con- 
tractions of  all  the  muscles  about  the  pharynx  and  larynx  will 
be  so  powerful  that  it  will  be  impossible  at  first  to  insert  any 
sort  of  a  tube  into  the  esophagus.  In  these  very  difficult  cases 
I  have  often  succeeded,  after  a  few  minutes  of  patient  persever- 
ance in  the  process  of  educating  the  oversensitive  pharynx  to 
the  presence  of  the  tube.  This  is  best  effected  as  follows :  Tell 
the  patient  that  you  desire  merely  to  accustom  his  throat  to 
the  novel  sensation  of  having  a  tube  in  contact  with  it  and 
that  you  will  not  attempt  to  pass  it  into  the  stomach  until 


SECRETORY     FUNCTION     OF    THE     STOMACH  IT3 

after  due  notice.  Then  while  the  patient  holds  his  mouth  wide 
open  with  the  tongue  well  forward,  carry  the  end  of  the  tube 
back  and  let  it  impinge  gently  against  the  posterior  wall  of 
the  pharynx.  There  will  be  immediately  a  reflex  contraction 
of  all  the  parts,  but  continue  to  hold  the  tube  there  for  a  few 
seconds  before  withdrawing  it.  After  a  little  delay  insert  the 
tube  in  the  same  way  again  and  repeat  this  procedure  three 
or  four  times  if  necessary,  calling  the  patient's  attention  mean- 
while to  the  fact  that  he  has  nothing  to  fear,  as  you  do  not 
intend  to  push  the  tube  on  further  without  notice.  In  this  way 
the  patient  regains  confidence  and  his  morbid  dread  of  the  tube 
is  largely  overcome.  After  such  a  brief  preliminary  training 
it  is  generally  quite  practicable  to  pass  the  tube  into  the  stom- 
ach successfully  and  often  with  very  little  inconvenience. 

Most  stomach  tubes  have  rings  marked  around  them  to  indi- 
cate how  far  they  should  be  introduced.  The  idea  is  to  push 
the  tube  on  until  the  ring  comes  to  the  teeth.  This  is  a  poor 
dependence.  The  distance  from  the  teeth  to  the  bottom  of  the 
stomach  varies  in  even  healthy  persons  according  to  their  height 
and  peculiarities  of  build,  and  in  conditions  of  displacement  or 
dilatation  of  the  organ,  which  are  exceedingly  common,  espe- 
cially in  women,  the  tube  may  have  to  enter  from  one  to 
possibly  seven  or  eight  inches  beyond  the  mark.  There  are 
two  ways  of  determining  how  far  to  introduce  the  instrument. 
The  easier  is  to  try  it  first  at  an  inch  or  so  above  the  mark, 
and  if  no  fluid  can  be  made  to  flow,  gradually  push  it  further, 
even  if  it  is  recjuired  to  pass  it  to  a  point  six  or  eight  inches 
beyond  the  mark.  When  liquid  will  flow  in,  it  must  return  if 
the  tube  has  been  passed  to  just  the  right  point  and  not  beyond 
it.  To  pass  it  too  far  is  as  bad  as  not  far  enough,  since  the 
end  may  then  curl  up  and  the  opening  emerge  above  the  level 
of  the  contents. 

The  surer  way  is  to  determine  first  by  one  of  the  methods 
previously  described  where  the  bottom  of  the  stomach  is,  and 
then,  having  measured  the  tube  over  the  outside  of  the  body, 
the  distance  necessary  to  insert  it  is  readily  seen. 


114  METHODS    OF    EXAMINATION 

Some  authors  speak  of  the  possibihty  of  the  entire  tube's 
being  swallowed  so  as  not  to  be  recoverable  without  an  opera- 
tion. This  could  never  happen  with  inexperienced  patients, 
who  are  always  trying  rather  to  force  the  instrument  out; 
and  only  the  grossest  carelessness  could  make  it  possible  with 
an  experienced  one.  The  long  tubes  now  mostly  in  use,  reach- 
ing two  to  four  feet  outside  the  mouth,  could  not  pass  entirely 
into  the  stomach  unless  intentionally  swallowed.  With  those 
having  a  bulb  on  them  for  the  purpose  of  forcing  air  through 
when  clogged,  or  a  soft  rubber  funnel  at  the  outer  end,  the 
accident  would,  of  course,  be  out  of  the  question. 

As  to  the  contra-indications  for  the  tube,  they  will  be  few 
when  you  have  become  so  expert  as  to  be  able  to  introduce  it 
without  letting  the  patient  become  unduly  excited.  But  it 
will  be  wisest  never  to  resort  to  its  use  soon  after  a  hemorrhage 


Fig.  21. — The  Kuttner  Aspirator, 

from  any  internal  organ,  in  cases  of  aneurism,  in  advanced 
lung  disease,  in  serious  forms  of  uncompensated  heart  disease, 
in  conditions  of  great  physical  debility  from  any  cause,  or  in 
the  acute  stage  of  gastric  ulcer. 

The  Kuttner  Aspirator. — Various  kinds  of  pumps  or  aspir- 
ators may  be  employed  for  the  purpose  of  emptying  the  stom- 
ach.    The  best  is  the  kind  in  use  in  Ewald's  clinic,  and  is  the 


SECRETORY     FUNCTION     OF    THE     STOMACH 


115 


invention  of  Kuttner,  long  Ewald's  first  assistant.  These  are 
now  to  be  had  at  some  of  the  instrument  makers  in  the  United 
States,  and  a  cut  of  one  is  herewith  shown.  I  imported  one  in 
1895,  and  was  the  first  writer  in  this  country  to  describe  and 
recommend  it.  It  is  similar  to  the  Politzer  air  bag,  only  larger, 
of  thicker  rubber,  and  without  any  valve  at  the  top.  It  is  first 
compressed  with  the  hand,  and,  while  held  so,  the  nozzle  is 
introduced  into  the  end  of  the  tube.     Then,  when  allowed  to 


Fig.  22. — Kuttner  aspirator  with  tube  attached. 

expand,  after  being  carried  down  to  a  point  below  the  level 
of  the  lower  border  of  the  stomach,  sufficient  suction  is  exerted, 
with  the  help  of  siphonage,  to  empty  the  contents  of  the  stom- 
ach with  a  minimum  of  disturbance  or  inconvenience  to  the 
patient. 

If  the  tube  should  be  blocked  with  mucus  in  passing  down, 
as  sometimes  happens,  no  contents  will  flow  out.  In  this  case 
you  should  disengage  the  bulb,  and  attach  it  to  the  tube  again 
without  compression.    Then,  by  compressing  it,  you  will  force 


Il6  METHODS    OF    EXAMINATION 

its  contained  air  downward  through  the  tube  and  thus  clear  out 
the  obstruction.  The  air  thus  forced  into  the  stomach  causes 
little  or  no  inconvenience  though,  exceptionally,  enough  of  it 
may  return  with  the  fluid  contents  to  fill  the  bulb  and  prevent 
a  complete  emptying.  You  should  then  detach  the  bulb  again 
and  introduce  it  compressed.  This,  provided  the  tube  has  been 
inserted  just  far  enough,  rarely  fails  to  bring  up  either  all  the 
contents,  or  15  to  30  c.  c,  which  are  enough  for  all  the  neces- 
sary tests.  If  not,  the  difficulty  may  be  that  the  stomach  con- 
tents have  passed  prematurely  into  the  duodenum  as  a  result 
of  excessive  peristaltic  action  or  pyloric  insufficiency.^ 

lit  is  now  a  well-established  fact  that  normally  when  there  is  an 
adequate  secretion  of  HCl,  the  pylorus  rhythmically  opens  and  closes  at 
short  intervals  during  gastric  digestion,  but  that  when  the  HCl  is 
insufficient,  the  pylorus  remains  too  continuously  open,  so  that  at  least 
the  liquid  parts  of  the  gastric  contents  pass  out  too  rapidly. 


LECTURE  VIII 

TEST    MEALS   AND     PREPARATIONS    FOR 
TESTING  THE  STOMACH  CONTENTS 

Concerning  Test  Meals. — In  order  to  determine  the  secre- 
tory activity  of  the  gastric  glands  it  is  customary  to  make 
chemic  and  microscopic  tests  of  samples  of  stomach  contents 
obtained  as  nearly  as  possible  at  the  height  of  the  digestive 
process,  w^hich  is  about  one  hour  after  the  Ewald  test  breakfast, 
or  from  two  or  four  hours  after  mixed  meals  including  meat, 
vegetables,  bread,  etc.,  the  exact  length  of  time  depending 
upon  the  size  of  the  meal.  About  two  hours  and  a  half  after 
the  average  hearty  American  breakfast  answers  well.  When 
vomiting  chances  to  occur,  especially  at  a  suitable  interval  after 
eating,  the  vomitus'  can  be  utilized  for  the  purpose  of  the  ex- 
amination. This,  however,  will  generally  give  less  accurate 
results,  since  the  fact  of  vomiting  presupposes  an  exceptionally 
disturbed  condition  of  the  stomach  at  the  time  and  moreover  it 
is  rare  that  the  patient  happens  to  vomit  at  the  period  when 
digestion  is  at  its  height.  Ordinarily,  therefore,  test  meals  of 
some  kind  are  employed  for  the  purpose  of  obtaining  samples 
of  the  stomach  contents  for  examination. 

The  Ewald  Breakfast. — A  convenient  meal,  and  that  which 
is  in  most  frequent  use  in  both  Europe  and  America,  is  the 
Ewald  test  breakfast.  It  consists,  according  to  Ewald  him- 
self, of  an  ordinary  stale  roll  and  one-third  of  a  liter — about 
two-thirds  of  a  pint — of  fluid.  The  fluid  may  be  either  water 
or  weak  tea,  without  sugar  or  milk.  Tea  is  that  most  usually 
ordered  by  Ewald  and  his  assistants  at  their  clinic  in  Berlin. 
A  goblet  and  a  half  of  water,  not  ice  cold,  answers  the  purpose 
quite  as  well,  and  is  what  I  usually  order  for  my  own  patients. 

117 


Il8  METHODS    OF    EXAMINATION 

In  place  of  the  roll,  two  moderate  slices  (or  a  little  less  than 
two  ounces)  of  stale  bread,  or  even  half  a  dozen  water  crackers, 
not  soda  crackers,  will  suffice. 

Such  a  meal  should,  under  normal  conditions,  uniformly 
digest  into  a  thin  grayish  liquid  at  the  end  of  one  hour  from 
the  time  the  patient  begins  to  eat,  and  it  is  then  you  should 
withdraw  the  contents  for  examination  and  chemical  analysis. 

The  Test  Dinner. — Leube  and  Riegel  have  recommended 
and  used  largely  a  test  dinner  to  be  taken  in  the  middle  of  the 
day.  It  consists  of  400  c.  c.  (13  fluid  ounces)  of  soup,  60 
grams  (2  ounces)  of  beef,  and  50  grams  (i^  ounces)  of 
wheat  bread  or  a  roll.  Sometimes  a  potato  is  added.  The 
time  for  the  examination  of  this  meal  is  about  three  hours 
afterward. 

The  ordinary  American  generous  mixed  breakfast,  with 
meat,  bread  or  rolls,  potatoes  and  coffee,  approximates  closely 
the  Leube  test  meal,  and  in  the  case  of  new  patients  who 
present  themselves  for  the  first  time  two  to  three  hours  after 
such  a  meal,  you  may  find  it  convenient  to  empty  the  stomach 
at  once  for  the  purpose  of  analyzing  the  contents,  thus  gaining, 
without  delay,  important  and  sufficiently  reliable  information. 
But  when  such  patients  can  return  at  another  time,  you  should 
have  them,  if  possible,  take  subsequently  the  usual  Ewald  test 
breakfast,  which  affords  valuable  data  for  comparison  espe- 
cially since  it  has  come  to  be  accepted  as  the  standard  the  world 
over. 

Do  not  make  the  mistake  which  is  sometimes  made  of  at- 
tempting to  take  up  such  a  mixed  meat  meal  at  the  end  of  one 
hour,  since  it  will  then  be  so  little  digested  as  not  to  pass 
through  any  ordinary  tube  without  great  difficulty.  Pouring 
water  into  the  tube  may  facilitate  the  process,  but  spoils  the 
results  of  the  analysis.  Moreover,  testing  the  stomach  con- 
tents before  digestion  has  reached  its  height  would  not  afford 
results  of  value. 

The  Lactic-Acid-Free  Meal. — The  only  other  test  meal  of 
which  it  is  worth  while  to  tell  you  is  the  Boas  non-lacteaJ  one 


TEST    MEALS    AND    TESTING    STOMACH     CONTENTS        HQ 

for  the  purpose  of  testing  for  lactic  acid  in  suspected  cancer  of 
the  stomach.  Boas  advises  washing-  out  the  stomach  at  bed- 
time to  remove  all  traces  of  previous  food,  and  then,  in  the 
morning  following,  the  patient  takes  six  to  eight  ounces  of 
thin,  well-cooked  oatmeal  porridge,  which  is  prepared  and 
served  without  milk,  cream  or  sugar.  An  hour  afterward  this 
is  brought  up  in  the  usual  way.  Boas'  idea  was  that  all  breads, 
rolls,  etc.,  contain  milk  enough  to  contaminate  the  product 
with  lactic  acid.  But  the  view  formerly  advanced  by  him, 
that  even  a  very  small  percentage  of  lactic  acid  formed  in  the 
stomach  is  a  sign  of  gastric  cancer,  is  no  longer  accepted. 
Boas,  however,  still  maintains,  and  with  much  clinical  evidence 
in  his  support,  that  a  decidedly  large  amount  of  this  acid  in 
the  stomach,  when  not  introduced  with  the  food,  must  raise 
a  strong  suspicion  of  the  existence  of  carcinoma.  It  is  only 
exceptionally  in  the  worst  forms  of  chronic  gastric  catarrh, 
with  great  stagnation  and  an  unusually  excessive  amount  of 
fermentation,  that  a  large  proportion  of  lactic  acid  is  found  in 
the  stomach  without  the  presence  of  cancer.  Lactic  acid  can- 
not by  the  usual  simple  tests  be  demonstrated  in  the  stomach 
contents  in  the  presence  of  free  HCl. 

No  Single  Test  Meal  Conclusive. — No  one  of  these  test 
meals  is  sufficient  of  itself  to  determine  accurately  the  secretory 
activity  of  the  gastric  glands.  The  Ewald  test  breakfast  is 
nearly  identical  with  the  first  breakfast  of  a  large  proportion 
of  people  in  Germany,  except  that  as  a  rule  many  eat  butter 
with  their  bread  and  drink  coffee  instead  of  tea,  while  a  certain 
proportion  of  persons  add  one  or  two  eggs.  This  small  meal, 
therefore,  tests  with  substantial  accuracy  the  secretory  activity 
of  the  gastric  glands  in  Germany  and  in  many  parts  of  Europe 
where  the  inhabitants  habitually  break  their  fast  in  the  morn- 
ing with  such  a  light  repast.  In  the  United  States,  where  most 
persons  begin  the  day  with  a  hearty  meal  including  nearly 
always  either  meat  or  eggs,  it  does  not  supply  to  the  stomach 
its  accustomed  early  morning  food.  When  a  person  whose 
usual  breakfast  consists  of  a  large  beefsteak,   two  cups  of 


I20  METHODS    OF    EXAMINATION" 

Strong  coffee,  a  dish  of  fried  potatoes,  and  hot  griddle  cakes  or 
soda  biscuit  with  butter,  suddenly  substitutes  a  roll  and  ten 
ounces  of  tea  or  water,  the  gastric  glands  are  likely  to  secrete 
an  amount  of  HCl  and  pepsin  in  excess  of  the  requirements  of 
such  a  slender  meal  and  might,  therefore,  show  a  decided  HCl 
excess  which  would  not  be  apparent  after  his  usual  breakfast. 
Hence,  while  in  important  cases  you  should  make  one  test  by 
this  accepted  standard,  do  not  depend  upon  it  entirely. 

Then  again  it  is  a  fact  long  since  observed  by  me,  and  noted 
also  by  other  observers,  that  the  stomach  of  the  same  person 
will  secrete  far  different  amounts  of  gastric  juice  not  only  after 
meals  of  different  size,  but  also  at  different  times  of  the  day. 
For  example,  some  persons  secrete  but  little  gastric  juice  in 
the  early  part  of  the  day,  but  more  liberally  of  the  same  toward 
evening.  On  the  other  hand,  the  reverse  is  true  of  certain 
other  persons.  That  is,  patients  have  been  frequently  ex- 
amined by  me  who  after  an  Ewald  breakfast  in  the  morning 
had  a  large  amount  of  HCl  in  the  stomach  contents,  whereas 
in  the  latter  part  of  the  day,  owing  apparently  to  a  partial 
exhaustion  of  the  nerve  centers,  the  gastric  secretion  was 
markedly  insufficient. 

An  Objectionable  Method  of  Getting  the  Stomach  Con- 
tents.— It  is  still  advised  in  some  works  to  empty  the  stomach 
by  what  is  called  expression  w-hen  an  analysis  of  its  contents  is 
to  be  made.  That  is,  a  medium-sized  tube  is  passed  into  the 
stomach,  and  the  patient,  with  both  hands  over  the  epigas- 
trium, is  urged  to  make  straining  efforts.  By  holding  the 
breath  and  active  contractions  of  the  diaphragm,  the  contents 
of  the  viscus  are  sought  to  be  forced  up  through  the  tube. 
This  generally  succeeds  in  time  in  accomplishing  the  object,  but 
in  most  cases  only  after  such  an  amount  of  serious  discomfort, 
dyspnea,  retching,  and  often  vomiting,  as  must  disgust  any 
patient.  Indeed,  this  obnoxious  method  of  getting  up  test 
meals  and  unskillful  ways  of  performing  lavage  are  largely 
answerable  for  the  very  general,  though  needless,  dread  of  the 
stomach  tube. 


TEST    MEALS    AND    TESTING    STOMACH     CONTENTS  121 

Extraction,  however,  with  the  Kuttner  bulb  already  described 
is  a  very  simple  matter,  and  after  the  tube  has  been  swal- 
lowed, requires  usually  a  few  seconds  only  with  the  patient 
remaining  entirely  passive.  It  is  accomplished  still  more 
easily  and  rapidly  when  the  latter  voluntarily  assists  by  swal- 
lowing movements  and  deep  breathing. 

The  Macroscopic  Examination  of  the  Stomach  Contents. — 
In  conformity  w^itli  my  plan  to  describe  methods  that  ac- 
complish as  much  as  possible  for  the  purposes  of  both  diag- 
nosis and  treatment  by  the  simplest  means  with  no  more 
instrumentation  than  absolutely  necessary,  I  strongly  advise 
you  to  accustom  yourselves  to  a  careful  study  of  the  gross  ap- 
pearance and  other  manifest  characteristics  of  the  stomach 
contents,  whether  these  be  vomited  or  extracted  especially  for 
testing.  In  patients  who  are  used  to  the  tube  and  not  too 
much  inconvenienced  by  it,  it  is  often  advisable  to  extract  all 
of  the  stomach  contents  that  can  be  obtained  in  this  way. 

For  reasons  hitherto  explained  this  is  not  advisable  on  the 
occasion  of  the  first  introduction  of  the  tube  into  a  patient's 
stomach  for  diagnostic  purposes.  But  whether  you  bring  up 
all  the  contents  that  can  be  obtained  or  seek  only  to  extract 
enough  for  the  usual  qualitative  and  quantitative  tests,  great 
differences  may  be  observed  in  the  amounts  of  the  contents  that 
will  readily  be  extracted.  In  exceptional  patients  with  hyper- 
motility,  in  whom  the  expulsive  powers  of  the  stomach  are 
unusually  strong,  or  the  pylorus  unduly  relaxed,  you  will 
frequently  obtain  no  contents  at  all  if  you  wait  until  the  end 
of  an  hour,  as  is  the  usual  rule.  In  these  you  will  find  it 
(  necessary  to  take  up  the  contents  at  the  end  of  thirty,  forty, 
or  forty-five  minutes.  In  patients  having  a  normal  gastric 
motor  power  and  no  hyperacidity  to  complicate  matters  you 
may  ordinarily  obtain  an  hour  after  the  Ewald  test  breakfast 
has  been  begun,  from  half  an  ounce  to  three  or  even  four 
ounces  (15  to  60  c.  c.)  of  filtered  contents.  In  many  first 
attempts  even  with  new  patients  under  such  circumstances 
you  may  obtain  a  much  larger  amount  than  the  above  maxi- 


122  METHODS    OF    EXAMINATION 

mum,  and  in  your  trained  patients,  when  you  endeavor  to 
empty  their  stomachs  completely,  you  will  \'ery  frequently 
be  able  to  obtain  two  to  four  times  the  normal  amount.  If 
this  excessive  amount  consists  of  a  thin  watery  fluid  contain- 
ing no  solid  particles  and  ha^'ing  no  particular  odor,  except 
perhaps  that  of  new  bread,  you  can  infer  that  you  are  prob- 
ably dealing  with  a  case  of  HCl  excess  (hyperchlorhydria) 
and  possibly  gastric  ulcer.  This  inference  as  to  HCl  excess 
would  be  confirmed  if  the  patient  should  complain  of  a  sharp 
acid  taste  when  the  liquid  comes  into  the  mouth  and  pain 
one  to  three  hours  after  ineals. 

If  the  excessive  contents  obtained  should  consist  of  a  foul- 
smelling  mixture  of  a  fluid  having  numerous  fragments  of 
meat  or  undigested  bread  or  vegetables  as  well  as  considerable 
amounts  of  mucus  floating  through  it,  5'ou  may  suspect  a 
dilated  stomach  with  deficient  HCl  (hypoacidity)  and  prob- 
ably advanced  gastric  catarrh.  You  might  think  then  also 
of  cancer.  The  inference  that  you  were  dealing  with  hypo- 
acidity and  possibly  gastric  catarrh  or  cancer  would  be 
strengthened  if  the  patient  should  report  no  particularly 
sharp,  sour  taste  of  the  fluid  passing  through  his  mouth  and 
only  a  disgusting  and  bitter  taste  with  possibly  a  slight  sour- 
ness, such  as  may  be  produced  by  an  excess  of  organic  acids 
and  revealed  to  both  taste  and  smell.  The  latter  sort  of 
stomach  contents  when  allowed  to  stand  in  a  conical  glass 
usually  separates  into  several  layers,  the  uppermost  one  being 
frothy  on  account  of  the  large  content  of  gas  from  fermenta- 
tion. Beneath  this  is  a  layer  containing  much  oil  and  still 
lower  the  heavier  liquids  with  undigested  particles  of  food 
suspended  in  them.  Finding  an  excess  of  material  in  the 
stomach,  except  when  there  is  obstruction  to  the  outflow 
by  a  spasm  of  the  pylorus,  or  from  any  one  of  numerous 
other  possible  causes,  is  prima  facie  evidence  of  deficient 
motor  power  in  the  gastric  walls  and  often  means,  as  was 
mentioned  before,  dilatation  of  the  stomach  (gastrectasis). 
In   these   cases   several   pints   of   decomposing   contents   may 


TEST  MEALS  AND  TESTING  STOMACH    CONTENTS  I2T, 

sometimes  be  obtained  from  the  stomach.  Chronic  gastritis 
does  not  necessarily  coexist  with  this  condition,  though  it 
often  does,  and  in  such  cases  you  will  find  mucus  mixed  with 
the  stomach  contents.  It  is  proper  to  repeat  here,  however, 
that  the  finding  of  considerable  amounts  of  mucus  in  the 
stomach  does  not  of  itself  prove  the  existence  of  gastritis  or 
catarrh  of  the  organ.  The  catarrhal  process  may  be  situated 
in  the  nose  or  throat  and  the  mucus  merely  swallowed. 

Bile,  Blood,  Feces,  or  Pus  in  the  Stomach  Contents. — = 
Besides  considerable  amounts  of  mucus  and  of  undigested  food, 
other  morbid  constituents  usually  recognizable  by  the  naked 
eye  may  be  present,  such  as  bile  and  blood,  or  when  present 
in  large  quantities,  pus.  Feces  dependent  upon  obstruction  in 
the  lower  bowel  or  upon  a  fistulous  opening  from  the  stom- 
ach into  the  intestines  may  often  reveal  themselves  both  to 
sight  and  smell.  A  recent  hemorrhage  from  any  part  of  the 
interior  of  the  stomach,  if  considerable,  may  always  be  recog- 
nized macroscopically  as  well  as  microscopically.  When  the 
quantity  is  very  small  or  the  blood  has  undergone  changes,  it 
may  require  a  chemic  or  microscopic  test  to  demonstrate  its 
presence.  Blood  found  in  the  stomach  contents  may  have  come 
from  the  lungs  or  any  of  the  parts  above,  and  been  swallowed, 
but  when  its  origin  is  in  the  stomach  itself  it  most  frequently 
signifies  ulcer  or  cancer.  It  may  arise  from  cirrhosis  of  the 
liver,  exceptionally  as  the  result  of  so-called  vicarious  menstru- 
ation, and  still  more  exceptionally  from  swallowed  poisons  or 
foreign  bodies,  from  aneurisms  or  varices  in  the  stomach 
walls,  from  severe  forms  of  anaemia,  or  from  certain  acute 
infectious  diseases  or  constitutional  dyscrasise.  (See  Lecture 
LVIII.) 

The  fluidity  of  the  stomach  contents. is  more  important  than 
the  quantity  obtained,  so  far  as  concerns  the  secretory  function 
of  the  viscus.  When  the  gastric  juice  is  normal  in  quantity 
and  activity,  the  stomach  contents  should  be  a  somewhat  viscid 
fluid  resembling  rich  milk  in  consistency.  They  should  be  of 
a  grayish  color  after  the  Ewald  breakfast  and  will  vary  in 


124  METHODS     OF    EXAMINATION 

color  after  other  meals  according  to  the  character  of  the  food 
taken,  being  yellowish  after  a  meal  consisting  largely  of  eggs 
and  much  darker  after  a  meal  of  meat  and  vegetables.  When 
the  gastric  juice  is  very  strong  in  HCl  and  pepsin,  the  contents 
are  likely  to  be  thinner  and  more  fluid  than  normal,  flowing 
almost  as  freely  as  water,  and  rapidly  filtering  unless  mixed 
with  much  mucus.  An  admixture  of  "mucus  always  delays 
filtration.  T^he  more  deficient  and  inactive  the  gastric  juice, 
as  in  hypochlorhydria  and  hypopepsia,  the  less  perfect  will  be 
the  solution  of  the  stomach  contents.  Instead  of  perfect  fluid- 
ity there  may  be  a  mushy  condition,  the  chyme  being  so  thick 
that  it  will  scarcely  flow  through  the  tube,  or  it  may  contain 
portions  of  fluid  mixed  with  but  slightly  changed  bread  crumbs 
or  unchanged  pieces  of  other  food.  Thus  it  may  be  seen  that 
the  experienced  gastrologist  scarcely  needs  to  make  the  usual 
chemic  and  microscopic  tests  in  order  to  recognize  very  marked 
departures  from  the  normal  in  either  direction ;  but  such  tests 
are  very  valuable  whenever  it  is  desirable  to  have  an  accurate 
knowledge  concerning  the  great  majority  of  cases  in  which 
the  stomach  contents  will  be  found  to  occupy  a  middle  ground, 
partaking  of  the  character  of. neither  extreme. 

A  greenish-yellow  tinge  to  the  stomach  contents  may  result 
from  bile,  or  from  succinic  acid,  and  elsewhere  the  means 
of  making  a  differential  diagnosis  between  these  is  explained. 
Bile  is  always  present  in  the  small  intestine,  and  can  be 
recognized  by  Gmelin's  test  or  by  Pettenkofer's  test  for  the 
bile  acids.  Its  reflux  into  the  stomach  indicates  generally 
a  relaxed  condition  of  the  pyloric  valve,  but  may  be  due  to 
obstruction  of  the  intestine  below  the  entrance  of  the  bile 
duct  or  to  the  straining  of  vomiting,  etc.  Much  pus  in  the 
stomach  contents,  recognizable  by  the  naked  eye,  would  mean 
usually  a  serious  abscess  in  the  gastric  wall  or  esophageal 
wall;  but  smaller  amounts  of  pus  discovered  by  the  micro- 
scopic examination  may  have  been  swallowed,  having  their 
origin  then  in  ozena,  disease  of  the  gums,  or  some  other 
inflammatory  condition  in  any  of  the  parts  above. 


TEST    MEALS    AND   TESTING   STOMACH    CONTENTS  I25 

Filtering  the  Stomach  Contents. — Having  obtained  a 
sample  of  the  stomach  contents  whether  by  means  of  the 
instruments  ah-eady  described  or  by  vomiting,  and  studied 
carefully  its  gross  appearance  macroscopically,  your  next  step 
should  be  to  measure  the  total  quantity  obtained  and  filter 
it.  Chemists  and  other  trained  laboratory  workers  will  not 
need  instructions  concerning  these  minor  details;  but  for 
students  and  general  practitioners,  it  is  particularly  desirable 
to  make  everything  as  plain  as  possible. 

Procure  a  good  quality  of  filter  paper  and  cut  into  squares, 
or  better,  circles,  about  eight  inches  in  diameter.  Fold  one  of 
these  in  such  a  manner  that  it  will  form  a  cone  with  folds 
radiating  in  every  direction  from  the  apex.  Put  this  inside  a 
glass  funnel  of  three  or  four  inches'  diameter,  and  place  the 
latter  in  any  convenient  wide-mouthed  bottle.  Empty  the 
sample  of  stomach  contents  obtained,  or  a  sufficient  quantit}'- 
thereof,  into  this  funnel  and  set  it  aside  to  filter.  Provided 
there  be  a  good  quantity  of  it  and  a  large  amount  of  mucus 
be  not  present,  filtration  will  go  on  rapidly,  so  that  within  fif- 
teen or  twenty  minutes  you  should  have  enough  of  the  filtrate 
to  enable  you  to  make  not  only  the  indispensable  simpler  qual- 
itative tests,  but  also  if  need  be,  some  of  the  quantitative  tests. 

When  the  contents  are  very  viscid  you  will  save  much  time 
by  using  a  filter  pump  or  suction  pump,  which  can  be  readily 
attached  to  the  faucet  and  is  not  expensive.  You  can  then 
insert  the  funnel  into  a  rubber  stopper  which  closes  a  filtering 
flask,  the  latter  being  connected  with  the  filter  pump  by  means 
of  rubber  tubing.  In  the  absence  of  a  water  supply,  an  ordi- 
nary hand  aspirator  may  be  connected  with  the  filter  bottle,  and 
sufficient  contents  filtered  by  compressing  the  bulb  several 
times.  The  filter  should  be  protected  from  tearing  by  placing 
a  plug  of  absorbent  cotton  at  the  bottom  of  the  glass  funnel.  A 
platinum  cone  is  preferable  for  this  purpose,  but  is  expensive. 


LECTURE  IX 

QUALITATIVE   TESTS    OF   THE    STOMACH 
CONTENTS 

The  Simpler  Tests  for  HCl. — If  a  strip  of  congo-red  test- 
paper  dipped  into  the  extracted  stomach  contents  or  vomited 
matter  is  changed  to  a  decided  bkie  or  blue-black  color,  it 
means  free  acid  of  some  kind  and  nearly  always  free  HCl.  If 
the  change  is  not  well  marked  it  may  mean  free  organic  acids 
such  as  result  from  fermentation.  Adding  now  a  drop  or 
two  of  a  one-half  per  cent,  alcoholic  solution  of  dimethyi- 
amido-azo-benzol  ( to  be  obtained  of  ]\Ierck,  or  any  wholesale 
chemist)  will  produce  a  bright  cherry-red  color  if  the  free 
acid  should  be  HCl.  This  test  may  prove  misleading  in  the 
rare  contingency  of  there  being  present  0.2  per  cent,  or  more 
of  lactic  acid,  or  in  case  of  a  very  large  excess  of  any  of  the 
organic  acids,  which  may  produce  a  similar  color.  If  in  doubt, 
vou  should  test  also  by  the  Giintzburg  reagent,  which,  as  modi- 
fied by  Boas,  is  composed  as  follows : 


IJ     Phloroglucin 2.00 

Vanillin i.oo 

Alcohol  (80  p.  c.) 100.00 

M. 

This  should  have  been  recently  prepared,  else  it  cannot  be 
depended  upon. 

To  test  for  free  HCl  add  a  full  drop  of  this  to  a  very  small 
drop  of  the  stomach  contents  on  a  porcelain  dish  fa  butter 
plate  will  answer)  and  heat  slowly  over  a  small  flame.  If  free 
HCl  be  present,  a  brilliant  carmine  hue  will  be  developed  as  the 
liquid  evaporates.     This  is  the  most  reliable  test.     The  red 

136 


QUALITATIVE     TESTS     OF     THE     STOMACH     CONTEXTS      12/ 

color  with  this  test  is  not  produced  by  anything  except  a  free 
mineral  acid,  and  HCl  is  the  only  free  mineral  acid  to  be  found 
in  the  stomach  unless  taken  in  through  the  mouth.. 

It  is  desirable  in  many  cases  to  make  the  Uilelmann  test  for 
lactic  acid.  If  no  reaction  pointing  to  free  HCl  has  been  ob- 
tained, or  if,  with  the  dimethyl,  etc.,  reagent,  you  have  obtained 
a  reddish  color,  but  are  uncertain  as  to  its  significance,  you 
should  always  make  it.     The  test  is  carried  out  as  follows : 

Test  for  Lactic  Acid. — Add  lo  c.  c.  of  a  4  per  cent,  solution 
of  carbolic  acid  to  20  c.  c.  of  water  in  which  a  drop  of  the 
officinal  solution  of  the  chloride  of  iron  has  been  dissolved. 
Now  pour  equal  quantities  of  the  blue  liquid  which  results 
into  each  of  two  test  tubes.  To  one  of  these  add  drop  by  drop 
a  quantity  of  the  stomach  contents.  If  any  notable  proportion 
of  lactic  acid  be  present,  the  blue  will  be  replaced  by  a  peculiar 
greenish — or  citron-yellow  color.  The  change  to  an  ordinary 
yellow  color  does  not  signify  lactic  acid.  The  presence  of 
free  HCl  or  of  much  peptone  may  prevent  this  reaction,  and 
oxalic  or  citric  acid,  alcohol,  phosphates,  or  dextrose  might 
possibly  mislead  by  giving  a  somewhat  similar  reaction,  but 
are  rarely  present  in  sufficient  cjuantity  one  hour  after  the 
Ewald  breakfast.  In  any  case,  two  of  the  tests  just  described 
should  give  conclusive  results.  Thus,  if  there  be  a  reaction 
with  the  dimethyl,  etc.,  and  none  with  the  Uffelmann  test, 
there  is  free  HCl  and  no  important  proportion  of  lactic  acid 
present.  If  there  should  be  a  decided  and  unquestionable 
response  to  the  Uffelmann  test,  with  or  without  a  reaction  to 
the  dimethyl  reagent,  the  presence  of  a  considerable  amount 
of  lactic  acid  would  be  shown,  pointing  to  either  cancer  or 
advanced  gastric  catarrh  with  much  stagnation  and  fermenta- 
tion. In  such  a  case  the  Giintzburg  and  other  confirmatory 
tests  should  always  be  made,  and  a  thorough  exploration  of 
the  stomach  by  an  expert,  both  externally  and  internally,  would 
be  desirable. 

Whenever  the  various  tests  show  an  absence  of  free  HCl, 
you  should  always  make  the  foregoing  test  for  lactic  acid,  since 


128  METHODS    OF    EXAMIXATION 

it  may  be  present  in  such  cases  in  considerable  proportion 
and  may  then  mean  cancer  of  the  stomach,  though  it  is  not 
proof  positive  of  that  disease.  A  very  decided  response  to  the 
Uffelmann  test  must  ahvays  raise  the  suspicion  of  cancer,  or 
tend  to  confirm  such  a  suspicion  when  a  tumor  can  be  made 
out. 

When,  from  any  cause,  the  result  of  the  Uffelmann  test  is 
uncertain  or  it  is  desired  to  make  the  test  with  unusual  care, 
you  may  practice  the  following  modification  of  it :  Place  in  a 
stoppered  separating  funnel  5  to  lo  c.  c.  of  the  filtered  stomach 
contents  and  add  twice  the  amount  of  pure  sulphuric  ether, 
being  especially  careful  that  it  is  free  from  alcohol.  Shake  this 
well  several  times  during  an  interval  of  twenty  minutes  and 
then  let  it  stand  until  the  liquids  separate  into  different  layers. 
Then  allow  the  ether  to  evaporate,  a  process  which  can  be 
hastened  by  placing  it  over  a  hot-water  bath.  The  residue 
should  then  be  dissolved  in  10  c.  c.  of  water  and  the  solution 
tested  for  lactic  acid  according  to  the  method  above  given. 
This  is  more  delicate  than  the  simple  Uffelmann's  test  without 
ether  and  gives  a  much  more  decided  reaction  to  even  minute 
quantities  of  lactic  acid  than  does  any  of  the  substances  before 
mentioned  as  liable  to  cause  similar  and  misleading  re- 
actions. 

A  very  quick  and  convenient  method  of  determining  roughly 
when  lactic  acid  is  present,  is  to  add  two  drops  of  the  officinal 
chloride-of-iron  solution  to  a  medium-size  test  tube  filled  with 
distilled  water,  pour  one-half  of  this  into  another  test  tube  of 
the  same  diameter,  and  then  add  to  one  of  them  several  drops 
of  the  filtered  stomach  contents.  If  lactic  acid  be  present,  the 
liquid  in  the  test  tube  to  which  the  filtrate  was  added  will  show 
the  same  greenish-yellow  color  described  as  produced  by  the 
usual  Uffelmann's  test.  This  is  the  method  of  testing  for 
lactic  acid  which  I  found  much  used  in  Ewald's  laboratory  in 
Berlin,  and  it  answers  well  enough  in  cases  where  great 
exactness  is  not  required. 

Tests  for  the  Other  Organic  Acids. — Whenever  large  quan- 


QUALITATIVE     TESTS     OF     THE     STOMACH     CONTENTS     1 29 

titles  of  the  organic  acids  are  present  in  the  stomach  contents 
at  the  usual  time  after  extracting  any  of  the  test  meals,  fer- 
mentation has  been  taking  place  to  an  abnormal  extent,  except, 
of  course,  when  these  acids  have  been  ingested  with  a  meal.  Bu- 
tyric, acetic,  and  succinic  acids  may  any  of  them  be  found  when 
there  is  excessive  fermentation,  and  the  differentiation  of  them  is 
not  generally  of  great  consequence  except  that  it  enables  you  to 
exclude  from  the  diet,  in  so  far  as  practicable,  those  articles 
which  are  most  prone  to  the  kind  of  fermentation  thus  shown 
to  exist.  The  two  former  are  easily  recognized  by  the  odor, 
acetic  having  the  odor  of  vinegar,  and  butyric  that  of  rancid 
butter.  Acetic  acid,  after  being  carefully  neutralized,  gives  a 
blood-red  reaction  on  the  addition  of  a  drop  or  two  of  a  solu- 
tion of  chloride  of  iron.  Butyric  acid,  on  the  addition  of  a 
small  piece  of  chloride  of  calcium,  may  reveal  itself  in  the  form 
of  small  drops  of  oil.  Succinic  acid  is  a  product  of  mold  for- 
mation in  the  stomach,  and  Knapp  ^  considers  it  indicative 
of  a  somewhat  serious  form  of  fermentation.  He  believes 
that  it  is  oftener  present  than  generally  supposed,  being  mis- 
taken for  bile  on  account  of  the  greenish-yellow  color  with 
which  it  tinges  the  stomach  contents.  It  may  be  recognized 
by  producing. a  dark  mahogany  ring  when  an  ethereal  extract 
of  the  chyrne  is  floated  on  a  o.  i  per  cent,  solution  of  ferric 
chloride  in  water. 

Tests  of  the  Salivary  Digestion. — Normally  the  ptyalin  of 
the  saliva  begins  to  act  in  the. mouth  during  mastication,  and 
the  action  continues  in  the  stomach  before  the  contents  of  the 
latter  become  too  acid,  and  the  conversion  of  the  starchy  part 
of  the  food  is  carried  through  various  stages  up  to  the  form 
of  sugar  known  chemically  as  maltose.  To  test  the  extent  to 
which  starch  digestion  has  thus  progressed,  you  should  put  a 
few  drops  of  the  stomach  contents  on  one  side  of  a  small  plate, 
such  as  a  butter-dish,  and  a  short  distance  away  from  it  one 
or  two  drops  of  Lugol's  solution,  which  is  prepared  as  follows: 
iodine,  o.i ;  potass,  iod.,  0.2;  water,  200  c.  c. 
^  Med.  Rec,  September  6,  1902. 


130  METHODS    OF    EXAMINATION 

Then,  by  tilting  the  dish,  let  the  two  fluids  come  together, 
and  note  the  color  changes  as  they  mingle.  A  blue  color 
would  indicate  either  wholly  unchanged  starch  or  starch  ad- 
vanced one  stage  in  digestion  to  amylodextrin.  Any  shade  of 
violet,  red,  or  a  mahogany  brown,  would  indicate  that  the 
starch  conversion  had  progressed  to  the  next  stage,  known  as 
erythrodextrin.  If  the  process  has  progressed  still  further, 
the  fluids  will  have  the  yellowish  color  of  iodine,  and  the  prod- 
uct of  the  starch  thus  far  digested  is  known  as  achroodextrin. 
This  is  as  far  as  the  color  reaction  can  help  us  in  recognizing 
the  degree  of  starch  conversion,  but  when  maltose  has  been 
formed  it  can  be  recognized  by  the  usual  tests  for  sugar. 
Normally,  the  starch  in  an  Ewald  test  breakfast  should,  at  the 
end  of  an  hour,  show  either  a  yellowish  or  brownish  tinge  with 
the  iodine  and  not  a  blue  one. 

A  more  delicate  way  of  carrying  out  this  test  is  to  put  about  2 
c.  c.  or  more  of  the  filtered  contents  in  a  test  tube  and  pour  2— 
3  drops  of  the  Lugol's  solution  on  the  side  of  the  inclined  tube. 
As  the  two  solutions  mingle,  a  play  of  colors  results.  If  in 
doubt  as  to  the  tint,  mix  the  two  solutions  and  dilute  with  a 
considerable  quantity  of  water.  The  slightest  tint  can  then  be 
appreciated. 

Tests  for  Pepsin  and  the  Rennet  Ferment. — To  test  for 
pepsin,  add  to  5  c.  c.  of  the  filtered  stomach  contents  one  of 
the  disks  of  albumin  to  be  had  of  the  dealers  or  small  fragments 
of  coagulated  white  of  ^%g,  and  if  there  be  no  HCl  present,  add 
2  or  3  drops  of  this  acid  and  set  aside.  When  pepsin 
is  present  in  the  usual  amounts,  the  albumin  should  be  all 
dissolved  in  the  course  of  five  to  six  hours,  and  the  more  rap- 
idly it  dissolves,  as  a  rule,  the  larger  is  the  proportion  of 
pepsin.  You  can  prepare  suitable  disks  of  albumin,  one-six- 
teenth inch  thick  and  one-qukrter  inch  in  diameter  by  cutting 
them  out  of  the  white  of  a  hard-boiled  ^%%.  A  supply  of  these 
should  be  kept  on  hand  in  50  per  cent,  glycerin.  Wash  these 
disks  well  before  using. 

You  may  test  for  the  rennet  ferment  as  follows :  Neutralize 


QUALITATIVE     TESTS     OF     THE     STOMACH     CONTENTS     13 1 

5  c.  c.  of  the  filtered  stomach  contents  by  the  addition  of  a 
solution  of  caustic  soda  until  blue  litmus  paper  is  no  longer 
reddened  by  it.  Then  add  5  c.  c.  of  fresh  pure  milk,  which 
should,  if  necessary,  also  be  rendered  neutral  in  reaction.  Shake 
the  mixture  well  and  let  it  be  kept  at  about  the  body  tempera- 
ture, either  in  an  incubator  or  a  glass  of  warm  v/ater  (about 
40°  C).  If  rennin  is  present  in  normal  proportions,  a  firm 
coagulum  should  form  in  ten  to  fifteen  minutes.  A  slower 
reaction  would  indicate  a  deficiency  of  the  rennet  ferment,  and 
an  entire  failure  of  coagulation,  the  absence  of  such  ferment. 

Tests  for  Albumin,  Propeptone,  and  Peptones. — The  more 
completely  any  sample  of  stomach  contents  is  digested  the  less 
albumin  there  should  be  present,  and  you  may  learn  something 
therefore  concerning  the  degree  to  which  the  digestive  process 
has  been  carried  by  putting  4  or  5  c.  c.  of  the  filtered  stomach 
contents  into  a  test  tube  and  boiling  it  over  a  Bunsen  burner. 
Then  set  aside,  and  the  amount  of  the  deposit  shows  the  pro- 
portion of  albumin.  Neutralize  exactly  by  adding  a  weak 
solution  of  caustic  soda,  which  precipitates  the  syntonin.  Then 
filter  the  contents  of  the  tube  in  order  to  get  rid  of  the  coasfu- 
lated  albumin  and  the  syntonin  and  make  the  test  for  propep- 
tone and  peptones  which  will  show  roughly  to  what  extent  the 
digestion  of  proteids  has  been  carried.  After  filtering,  add  to 
the  filtrate  an  equal  quantity  of  a  saturated  solution  of  sodium 
chloride — common  salt — and  shake  well.  If  propeptone  is 
present  it  will  be  precipitated  and  the  more  turbid  the  mixture 
becomes  the  larger  is  the  amount  of  the  propeptone.  Then  the 
addition  of  a  few  drops  of  commercial  acetic  acid  will  reveal 
flocculent  masses  when  this  is  present.  To  test  for  peptones 
filter  out  any  propeptone  that  may  have  been  found  and  pro- 
ceed thus  with  the  filtrate :  Render  the  liquid  decidedly  alkaline 
by  the  addition  of  a  sufficient  quantity — 3  or  4  drops — of 
the  one-tenth  normal  sodium  hydrate  solution  to  be  referred 
to  later  under  the  head  of  Quantitative  Analysis.  Add  also 
one  or  two  drops  of  a  i  per  cent,  sulphate  of  copper  solution. 
If  then  peptones  are  present,  what  is  called  the  biuret  reaction 


132  METHODS    OF    EXAMINATION" 

is  caused,  which  produces  a  rose  red,  purphsh,  or  strawberry 
tint  in  the  hquid. 

EXTERNAL  METHOD  OF   TESTING  FOR  GASTRIC  ACIDITY 

A  Further  Development  of  the  Benedict  Effervescence  Test. 

- — During  recent  years  I  have  made  a  large  use  of  Dr.  A.  L. 
Benedict's  effervescence  test  for  gastric  acidity,  and  have 
found  it  of  distinct  value,  especially  in  cases  in  which  the 
stomach  tube  could  not  be  introduced.  It  is  an  ingenious  and 
very  simple  method.'  As  described  by  him  in  various  com- 
munications, it  consists  essentially  in  administering  to  the 
patient  at  the  height  of  digestion — say  an  hour  after  the  Ewald 
breakfast — a  sufficient  cjuantity  of  sodium  bicarbonate  dis- 
solved in  water,  and  then,  with  the  stethoscope  previously  in 
position  over  the  epigastrium,  noting  the  amount  of  efferves- 
cence produced  as  revealed  by  the  resulting  crackling  or  bub- 
bling sounds.  When  a  notable  amount  of  these  sounds  can  be 
heard  through  the  stethoscope  one  may  always  infer  the 
presence  of  some  free  acid  in  the  stomach,  and  when  an 
unusually  large  amount  of  effervescence  is  thus  demonstrable, 
the  amount  of  free  acid  present  is  manifestly  correspondingly 
large. 

The  objection  has  been  made  that  this  free  acid  need  not 
necessarily  be  hydrochloric,  but  may  be  some  one,  or  a  com- 
bination, of  the  organic  acids  produced  by  fermentation. 
This  is  possible  in  rare  cases,  when  fermentation  is  very  exces- 
sive, as  in  cancer  or  aggravated  catarrh ;  but  the  skilled 
diagnostician  can  usually  determine  whether  or  not  much 
fermentation  is  going  on  in  the  stomach.  In  such  a  case  there 
is  likely  to  be  a  heavily  furred  tongue,  bad  breath,  poor  appetite, 
troublesome  eructations,  and  marked  gaseous  distention  of  the 
stomach,  while  most  of  tliese  s^miptoms  are  usually  absent,  or 
present  in  a  slight  degree  only,  when  the  percentage  of  HCl  in 
the  stomach  contents  is  either  normal  or  excessive.     They  are 

"'The  effervescent  Test  for  Gastric  Acidity,"  by  Dr.  A.  L.  Benedict, 
Inteniatiojial  Medical  Magazine,  June,  1903. 


QUALITATIVE    TESTS    OF    THE    STOMACH    CONTENTS       I33 

never,  according  to  my  experience,  all  fonncl  coexisting  in 
either  of  the  latter  conditions;  and  they  are,  on  the  other 
hand,  very  generally  all  to  be  noted  in  marked  cases  of 
organic  fermentation  when  free  HCl  is  absent  or  deficient. 

If  the  stomach  be  washed  downward  by  drinking  a  pint  of 
tepid  water  early  in  the  morning,  and  an  hour  later  an  Ewald 
breakfast  be  eaten,  only  a  very  small  portion  of  organic  acid 
will  usually  form  within  an  hour.  Any  notable  effervescence 
produced  by  the  soda  at  the  end  of  an  hour  would  thus  neces- 
sarily come  from  HCl. 

The  Percussion  Note  before  and  after  Drinking  a  Solution 
of  Soda. — I  have  developed  this  ingenious  method  a  little 
further  by  briefly  noting  carefully  before  administering  the 
soda  how  much  resonance  there  is  on  percussion  over  all 
parts  of  the  stomach,  and  then  again  after  the  patient  has 
swallowed  the  soda  solution  and  a  few  minutes  have  elapsed 
to  permit  of  its  chemical  combination  with  any  acid  present. 
The  difference  between  the  percussion  note  before  and  after 
this  little  procedure  is  very  striking  whenever  the  percentage 
of  the  HCl  preseirt  is  either  normal  or  excessive.  I  have 
demonstrated  this  fact  many  times  by  inflating  the  stomach 
with  soda  solution,  and  then,  on  the  following  day,  giving 
the  test  breakfast  and  analyzing  some  of  the  gastric  contents 
in  the  usual  way.  Indeed,  it  is  my  uniform  custom  now  in 
determining  the  size  and  position  of  the  stomach  to  admin- 
ister first  three-fourths  to  a  teaspoonful  of  sodium  bicarbonate 
dissolved  in  a  goblet  of  water,  at  the  height  of  digestion  if 
possible,  and  note  whether  any  tympany  results  without  the 
further  giving  of  an  acid.  If  tympany  is  thus  produced, 
it  affords  me  an  early  evidence  of  the  probable  presence  of 
abundant  HCl,  and  I  can  proceed  at  once  with  my  work  of 
mapping  out  the  boundaries.  If  no  tympany,  and  not  even  a 
moderate  increase  of  resonance,  results,  I  administer  addi- 
tionally 8  to  12  drops  of  strong  HCl  in  solution  (which 
I  find  preferable  to  tartaric  acid)  and  proceed  with  my  per- 
cussion. 


134  METHODS    OF    EXAMINATION 

When  the  soda  solution,  given  near  the  height  of  digestion, 
produces  no  increase  in  the  epigastric  resonance,  after  the 
region  has  been  gently  kneaded  for  a  few  moments,  it  is 
positive  evidence  that  there  is  very-  little  or  no  free  acid  in 
the  stomach. 

The  above  method  of  course  lacks  the  definiteness  and 
exactness  of  a  careful  chemical  analysis,  and  is  only  to  be 
recommended  as  a  substitute  when  the  latter  is  impracticable. 

Other  Substitutes  for  the  Chemical  Tests. — Einhorn's  Bead 
Test  ^  affords  another  method  of  learning  approximately  as 
to  the  efficiency  of  the  digestive  glands  in  cases  in  which  a 
tube  cannot  be  used.  It  consists  in  attaching  various  food 
substances  to  a  number  of  beads  which  are  swallowed  in 
a  capsule.  The  time  when,  and  the  condition  in  which,  these 
appear  in  the  stools  give  useful  information. 

Ad.  Schmidt  ^  has  devised  a  method  of  roughly  testing 
the  gastric  secretion  without  the  use  of  a  tube,  giving  lOO 
to  125  grams  (about  4  oz.)  of  finely  chopped,  raw,  smoked 
or  superficially  broiled  meat  (lean)  and  then  next  day  exam- 
ining the  stool  microscopically  for  connective  tissue  fibers. 
These  will  be  found  in  large  numbers  when  gastric  digestion 
is  deficient  in  activity. 

Sahli's  Desmoid  Test — Sahli  "^  early  in  1905  reported  that 
if  a  small  rubber  bag  containing  methylene  blue  and  tied  with 
catgut,  be  swallowed  after  a  hearty  meal,  normal  gastric 
digestion  will  be  shown  by  the  urine's  being  colored  a  bluish 
green  within  ten  hours.  Iodoform  taken  in  the  same  way 
should  cause  the  saliva  within  the  same  time  to  yield  a  violet 
color  with  starch  and  fuming  nitric  acid.  If  these  reactions 
fail  or  are  delayed,  Sahli  considers  stomach  digestion  absent 
or  deficient ;  but  the  test  is  not  certain,  as  the  catgut  may 
sometimes  be  dis^ested  in  the  bowel. 


'fe^ 


'^Jotir.  A.  M.  A.,  February  2,  1907. 
2  Ad.  vSchmidt,  Dentsch.  nied.  Woch.,  iSgg.     No.  49. 
^Correspondentzbl.  f.    Schweitzer aertze,  1905,  Nos.  8.  and  9.     Jour. 
A.  M.  A.,  May  12,  1906. 


LECTURE  X 

QUANTITATIVE  ESTIMATIONS  AND  MI- 
CROSCOPIC  EXAMINATIONS  OF  THE 
STOMACH    CONTENTS 


The  More  Important  Quantitative  Tests  of  the  Stomach 
Contents  here  described  can  be  readily  made  by  anyone  pos- 
sessing even  a  minimum  amount  of  chemical  knowledge. 

The  only  additional  apparatus  absolutely  required  is  a  grad- 
uated cubic-centimeter  measure  and  a  burette,  which  can  be 
obtained  at  a  trifling  cost.     (See  accompanying  illustration.) 


Fig,  23. — Burette  lor  quantitative  analysis. 

Premising  that  you  have  already  made  the  Giintzburg  quali- 
tative test  for  free  HCl,  I  will  now  state  how  you  may  deter- 
mine most  readily,  by  a  series  of  associated  tests,  the  quan- 
tities present  of  (i)  free  HCl;  (2)  combined  chlorine  (l  e.,  the 

135 


I3t>  METHODS    OF    EXAMINATION 

HCl  loosely  combined  with  the  albuminoids  of  the  food)  ;  and 
(3)  the  total  acidity  or  sum  total  of  all  the  free  and  combined 
acids,  mineral  and  organic.  This  is  called  Topfer's  method, 
and,;  while  less  scientifically  accurate  than  some  of  the  very 
elaborate  ones,  it  is  reliable  enough  for  practical  clinical  pur- 
poses in  all  cases  in  which  even  a  trace  of  free  hydrochloric 
acid  is  present,  and  also  in  other  cases,  except  those  in  which 
there  is  at  least  0.2  per  cent,  of  lactic  acid,  or  a  large  excess  of 
the  other  organic  acids  present,  as  shown  by  the  characteristic 
odor  of  vinegar  or  butyric  acid. 

In  chronic,  painful,  or  flatulent  indigestion,  the  treatment, 
medicinal,  dietetic,  and  mechanical,  should  be  very  different, 
when  there  is  a  deficiency  of  HCl,  from  that  imperatively  de- 
manded when  there  is  persistently  a  decided  excess  of  the 
same,  as  happens  in  a  large  proportion  of  all  such  cases. 

The  total  acidity  is  equally  important.  When  there  is  an 
absence  of  free  HCl  acid,  even  though  the  amount  of  the  com- 
bined chlorine  should  not  have  been  determined,  the  finding  of 
a  high  total  acidity — above  60 — would  point  to  an  excess  of 
organic  acids  from  fermentation,  while  a  very  low  total  acidity 
— 15  or  below — would  speak  in  favor  of  either  more  or  less 
complete  gastric  atrophy,  or  a  temporary  paralysis  of  secre- 
tion from  some  one  of  various  possible  causes. 

For  the  Topfer  test  you  will  need,  in  addition  to  the  burette 
with  graduated  measures,  pipettes  and  cups  or  beakers  holding 
two  or  three  ounces,  several  chemical  solutions,  as  fol- 
lows :  one-tenth  normal  solution  of  caustic  soda  which  should 
be  prepared  by  a  thoroughly  trained  chemist,  since  very  much 
depends  upon  its  absolute  accuracy;  but  you  can  obtain 
usually  from  any  reliable  dealer  the  normal  soda  solution 
and  dilute,  by  adding  one  part  to  nine  parts  of  distilled  water. 
Such  a  solution,  when  long  exposed  to  air,  becomes  weak- 
ened by  chemical  changes,  and  it  should  therefore  be  kept  in 
small  bottles  well  corked  and  always  full  up  to  the  cork. 
The  burette  must  be  filled  with  this,  preferably  up  to  the  zero 
mark,   before  beginning;   then,   besides,   the   following  three 


EXAMINATIONS    OF    THE    STOMACH    CONTENTS  13/ 

solutions  to  be  used  as  indicators :  ( i )  one-half  per  cent,  alco- 
holic solution  of  dimethyl-amido-azo-benzol ;  (2)  a  i  per 
cent,  watery  solution  of  alizarin,  which  is  known  chemically 
as  alizarin  monosulphonate  of  sodium;  (3)  a  i  per  cent,  alco- 
holic solution  of  phenolpthalein. 

No.  I  does  not  react  to  combined  HCl  or  acid  salts  of  any 
kind,  nor  to  moderate  amounts  of  the  organic  acids,  especially 
in  the  presence  of  peptones,  but  gives  a  brilliant  red  color  with 
the  faintest  admixture  of  HCl  in  the  free  form. 

No.  2  produces  a  clear  violet  color  when  mixed  with  a  solu- 
tion containing  any  of  the  acidities  to  be  found  in  stomach 
contents,  except  that  arising  from  the  presence  of  combined 
HCl,  or,  as  Van  Valzah  and  Nisbett  well  express  it,  alizarin 
"  is  sensitive  to  all  the  factors  of  gastric  acidity  except  the 
combined  HCl." 

No.  3  only  produces  its  characteristic  dark  red  color  in  the 
stomach  contents  when  all  the  elements  of  acidity,  including 
free  and  combined  acid  of  every  kind,  have  been  neutralized 
by  the  soda  solution. 

To  make  the  three  tests,  (a)  measure  into  a  beaker,  or  glass 
of  any  kind,  10  c.  c.  of  the  filtered  stomach  contents  (though 
5  c.  c.  will  answer  for  each  of  the  tests,  when  an  insufficient 
amount  of  the  contents  has  been  obtained)  and  add  to  it  two 
or  three  drops  of  the  No.  i — dimethyl-amido-azo-benzol.  A 
brilliant  carmine  color  is  produced  if  there  be  the  slightest 
proportion  of  free  HCl  present.  If  this  results,  place  the 
beaker  over  a  white  surface  and  add  the  soda  solution  from 
the  burette,  drop  by  drop,  till  the  bright  red  begins  to  fade  to 
a  dingy,  reddish  yellow.  This  shows  that  all  the  free  HCl 
has  been  neutralized.  Be  careful  to  stop  when  the  fading 
from  the  bright  red  first  becomes  decidedly  apparent.  Suppose 
the  result  of  this  process  (called  technically  a  titration)  to 
show  that  2.5  c.  c.  of  the  standard  soda  solution  were  necessary 
to  neutralize  10  c.  c.  of  the  gastric  contents.  This  would  be 
equal  to  ten  times  2.5,  or  25  c.  c.  of  the  solution  for  100  c.  c. 
of  contents,  and  all  such  calculations  are  made  upon  the  basis 


138  METHODS    OF   EXAMINATION" 

of  100  c.  c.  The  amount  of  free  HCl  would,  in  this  instance, 
be  expressed  arbitrarily  by  the  figures  25  by  some  authors, 
while  others  figure  out  the  exact  equivalent  percentage  of  free 
HCl  by  multiplying  the  finding  25  by  the  fraction  .00365, 
which  has  been  found  to  represent  very  nearly  the  amount  of 
HCl  which  each  c.  c.  of  the  soda  solution  will  neutralize. 
Making  this  multiplication  thus,  .00365X25=. 09125,  we 
obtain  the  decimal  fraction  .09125  as  expressing  the  percent- 
age of  free  HCl  present. 

(b)  Next,  to  10  c.  c.  of  the  stomach  contents  add  two  or 
three  drops  of  the  No.  2  (alizarin  solution)  and  titrate,  that  is, 
let  the  soda  solution  flow  into  the  mixture,  drop  by  drop,  until 
it  changes  it  to  a  clear  violet  tint.  Suppose  6  c.  c.  of  the  soda 
solution  to  have  been  used  in  this  titration,  we  multiply  by  10 
to  find  the  aggregate  amount  of  the  free  HCl,  organic  acids 
and  acid  salts,  but  not  including  the  combined  hydro- 
chloric acid,  i.  e.,  the  HCl  combined  with  the  albuminoids  of 
the  food.  It  will  be  remembered  that  alizarin  reacts  to  all 
the  elements  of  acidity  in  the  stomach  except  the  combined 
HCl.  We  have  then  obtained  the  figure  60  as  represent- 
ing conveniently  the  amount  of  these  combined  acidities  in 
100  c.  c.  of  the  fluid  being  tested.  As  only  a  small  part  of 
this  is  composed  of  HCl  in  any  form  there  is  clearly  no  excuse 
in  this  instance  for  multiplying  the  figure  60  by  the  fraction 
,00365  to  obtain  its  equivalent  value  in  terms  of  HCl. 

(c)  We  determine  by  a  third  titration  the  aggregate  of  all 
the  acid  elements,  mineral  and  organic,  free  and  combined, 
in  the  fluid  under  examination,  to  obtain  what  is  called  its  total 
acidity.     This  is  the  procedure : 

To  10  c.  c.  of  the  fluid  in  a  third  vessel  we  add  tw^o  or  three 
drops  of  the  No.  3  (phenolphthalein)  and  allow  the  soda  solu- 
tion to  flow  in  as  before.  Soon  a  circle  of  red  will  surround 
the  drops  of  the  alkaline  solution  as  they  fall  into  the  stomach 
contents,  fading  out  again  as  the  acids  at  first  quickly  neutral- 
ize it.  Later  the  whole  becomes  a  light  rose-red,  showing 
nearly  complete  saturation,  but  you  should  go  on  adding  the 


EXAMINATIONS    OF    THE    STOMACH    CONTENTS  1 39 

soda  until  each  drop,  as  it  falls  in,  no  longer  darkens  percept- 
ibly the  mixture.     Then  neutralization  is  complete. 

Suppose,  for  example,  8  c.  c.  to  have  been  used  in  this 
titration,  we  multiply  by  lo  and  obtain  80  as  the  total  acidity. 

Thus  we  have  by  these  three  titrations  ascertained  directly 
the  percentage  of  free  HCl,  and  the  figure  which  represents 
the  total  acidity.  Now,  as  the  third  titration  (c)  determines 
the  sum  total  of  all  the  acidities  present,  and  the  second  titra- 
tion (b)  reveals  the  amount  of  all  the  acidities  except  the  com- 
bined HCl,  it  is  manifest  that  we  have  only  to  subtract  the 
result  of  (b)  from  that  of  (c)  to  obtain  the  amount  of  the 
combined  HCl. 

Making  this  subtraction  with  the  hypothetical  figures  above 
given,  w^e  have  80 — 60=20.  In  this  instance,  it  is  proper  to 
multiply  the  20  by  .00365  in  order  to  obtain  the  actual  per- 
centage of  combined  HCl  present.  In  the  supposed  case  this 
would  be  2oX.oo365=.o730. 

This  may  seem  complicated,  and  a  little  puzzling  at  first, 
but  when  one  has  conveniently  at  hand  the  reagents  and  the 
few  appliances  required,  the  actual  processes  of  titration  may 
be  easily  and  quickly  performed,  while  the  calculations  are 
simple  enough. 

The  three  steps  may  be  thus  briefly  summarized : 

(a)  Find  how  many  c.  c.  of  the  soda  solution  are  required 
to  neutralize  the  measured  amount  of  the  stomach  contents 
with  No.  I  as  an  indicator,  and  multiply  this  by  10,  if  10  c.  c. 
of  the  contents  are  being  tested,  or  by  20,  if  only  5  c.  c.  are 
under  examination.     Set  down  the  product. 

(b)  Find  how  many  c.  c.  of  the  soda  solution  are  needed 
to  neutralize  a  like  portion  of  the  stomach  contents  with  No. 
2  and  multipl)^  as  before  to  obtain  the  result  for  100  c.  c. 

(c)  Find  how  many  c.  c.  of  same  solution  are  needed  to 
neutralize  an  equal  portion  of  the  stomach  contents  with  No. 
3,  and  multiply  as  before.  Subtract  the  result  (b)  from  that 
of  (c)  and  note  the  remainder.  The  result  of  (a)  multiplied 
by  .00365  gives  the  percentage  of  free  HCl ;  the  remainder  of 


I40  METHODS    OP    EXAMINATION 

(b)  from  (c)  multiplied  by  the  same  fraction  gives  the  per- 
centage of  combined  HCl,  and  the  figure  obtained  by  (c)  rep- 
resents the  total  acidity. 

Those  of  you  who  are  inexperienced  in  making  these  tests 
will  find  it  helpful  to  ha\'e  at  hand  control  solutions  as  follows : 
A  solution  of  HCl,  a  few  drops  to  the  ounce,  and  a  drop 
or  two  of  the  diamethyl,  etc.,  neutralized  by  a  solution  of 
caustic  soda  till  just  the  proper  shade  of  yellowish  red  has 
developed ;  also  a  i  per  cent,  solution  of  sodium  carbonate 
containing  a  drop  or  two  of  the  alizarin  solution.  Let  an 
experienced  chemist  prepare  these,  so  that  they  shall  show 
exactly  the  right  tints. 

Quantitative  Test  for  Lactic  Acid. — Numerous  methods 
have  been  devised  for  determining  the  proportion  of  lactic  acid 
present  in  the  chyme.  Most  of  these  are  rather  complicated, 
and  some  of  them  so  long  and  troublesome  as  to  be  quite 
impracticable  for  clinical  use.  Boas  has  devised  one  of  the 
most  reliable  and  delicate  of  these.  It  involves  a  very  tedious 
series  of  processes,  including  distillation,  and  is  never  employed 
except  for  strictly  scientific  purposes.  Boas  has  also  made  a 
large  use  of  the  following  simpler  method,  which  is  sufficiently 
exact  and  not  difficult : 

Add  to  IOC  c.  of  the  filtrate  a  few  drops  of  dilute  sulphuric 
acid,  heat  over  the  flame,  which  coagulates  the  albumin,  filter 
and  evaporate  over  a  water  bath  to  the*consistency  of  syrup, 
fill  up  to  the  original  amount  and  evaporate  again  to  a  small 
volume.  In  this  way  the  volatile  fatty  acids  are  removed  and 
the  residue  contains  only  lactic  acid.  The  residue  must  now 
be  extracted  with  200  c.  c.  of  ether,  the  ether  evaporated,  and 
what  remains  diluted  with  water  and  titrated  with  phenolph- 
thalein  and  one-tenth  normal  soda  solution.  Every  c.  c.  of  the 
one-tenth  normal  soda  solution  employed  corresponds  to  1.009 
per  cent,  of  lactic  acid. 

Quantitative  Test  for  Fatty  Acids. — The  following  method 
is  employed  by  Leo :  Determine  the  total  acidity  of  the  gastric 
contents.     Then  boil  10  c.  c.  till  the  vapor  given  off  ceases  to 


EXAMINATIONS    OF    THE    STOMACH    CONTENTS 


141 


show  an  acid  reaction.  Titrate  the  residue  with  one-tenth 
normal  caustic-soda  solution  with  phenolphthalein  as  an  indi- 
cator.    The  decrease  of  acidity  shows  how  much  of  the  fatty 


/ 


^^^^ 


Fig.  24. — Yeast.— From  a  photograph,  x  about  500.  The  preparation  was 
made  from  a  culture  obtained  from  the  contents  of  a  dilated  stomach. — 
From  Sidtiey  Martin'' s  "  Diseases  of  the  Stomach.'''' 

acids  were  present.  Adler  advises  that  the  proportion  of  HCl 
be  estimated  both  before  and  after  the  boiling,  so  that  allow- 
ance can  be  made  for  the  amount  of  this  acid  lost  in  the  boiling. 


A    O^ 


Fig.  26. — Sarcinseventriculi. 

A,  X, 600  seen  in  one  plane; 

B,  X  650,  diagrammatic, 
showing  the  appearance 
of  cotton-bales. — Flus'S'e. 


Fig.  25. — Bacillus  butyricus,  x  1020.  Sim- 
ple rods  are  seen  at  the  extreme  right 
of  the  figure;  also  swollen  and  spindle- 
shaped  spore-bearing  bacilli.  A,  a  spore- 
germinating. — Prazinowski. 

Microscopic  Examination  of  Stcmach  Contents. — Valuable 
information  can  also  frequently  be  obtained  by  a  microscopic 
examination  of  the  stomach  contents.  In  this  way  the  pres- 
ence of  yeast  fungi,  sarcinae,  various  forms  of  mold,  and 
numerous  other  micro-organisms  may  be  detected,  including 
especially  the  Boas-Oppler  bacilli,  which  last  are  considered 
as  being  to  some  extent  diagnostic  of  gastric  carcinoma.     The 


142  METHODS    OF   EXAMINATION 

character  of  the  epitheHal  cehs  obtained  from  the  stomach 
contents  and  wash  water  after  lavage  are  also  of  importance 
diagnostically.  When  such  cells  are  nearly  all  of  the  squamous 
type  or  of  the  ciliated  columnar  form,  any  mucus  present,  even 
though  in  large  quantity,  may  usually  be  set  down  as  having 
been  swallowed  and  not  secreted  by  the  stomach  itself.  On 
the  other  hand,  numerous  non-ciliated  columnar  or  cylindric 
epithelial  cells,  especially  when  they  show  evidences  of  fatty 
degeneration  and  stain  imperfectly,  indicate  an  inflammatory 
disease  of  the  gastric  mucous  membrane  itself.  The  discovery, 
microscopically,  of  numerous  groups  of  proliferated  or  degen- 
erated cells  points  to  the  existence  of  respectively  a  prolifera- 
tive or  an  atrophic  form  of  chronic  gastritis. 

Fragments  obtained  in  the  wash  water  in  the  case  of  sus- 
pected carcinoma  may  sometimes  afford  information  of  more 
or  less  value  when  examined  under  the  microscope.  Ewald, 
in  his  "  Diseases  of  the  Stomach,"  expresses  doubt  as  to  the 
possibility  of  recognizing  in  this  way  specific  cancerous  tissue, 
and  adds,  "  this  is  certainly  impossible  with  isolated  epithelial 
cells."  ' 

Riegel "  thinks  it  probable  that  characteristic  findings  may 
be  discovered  in  the  wash  water  microscopically  in  the  later 
stages  of  carcinoma,  but  Stockton,  the  American  editor  of 
the  English  translation  of  his  work,  in  commenting  upon  the 
foregoing,  adds  the  following  note : 

"  On  the  question  of  the  possible  early  determination  of  the 
presence  of  carcinoma  by  examination  of  the  fragments  of  the 
gastric  mucosa  recovered  in  the  wash  water,  Hemmeter  be- 
lieves that  he  has  occasionally  been  successful  in  making  a 
diagnosis  by  this  method.  Most  observers  regard  this  criterion 
as  absolutely  valueless.  Einhorn,  in  a  recent  article,  suggests 
that  the  diagnosis  of  carcinoma  of  the  stomach  may  be  made  in 
this  way  under  specially  favorable  conditions  if  a  direct  inva- 
sion of  the  gland-substance  by  epithelial  cells  can  be  observed." 

'  "  The  Diseases  of  the  Stomach."     By  Dr.  C.  A.  Ewald,  New  York,  1894 
2  Nothnagel's  Practice,  "  Disease  of  the  Stomach,"  Philadelphia,  1903. 


LECTURE  XI 

THE  URINE  IN  GASTRO-INTESTINAL  DIS 
EASE— URANALYSIS  AN  AID  IN  ESTI- 
MATING  THE    SECRETION    OF  HCl. 

Uranalysis  Indispensable  in  Gastro-Intestinal  Affections. — 

It  is  highly  essential  in  the  management  of  all  chronic  diseases 
to  make  thorongh  analyses  of  the  nrine  from  time  to  time.  It 
is  especially  important  to  do  this  in  affections  of  the  stomach 
and 'intestines,  since  here  so  much  useful  information  may  be 
thus  gained  which  cannot  be  obtained  in  any  other  way.  The 
digestive  processes  which  take  place  below  the  stomach  cannot 
be  investigated  with  any  certainty  or  satisfaction  except 
through  examinations  of  the  feces  and  urine;  and  examina- 
tions of  the  latter,  besides  being  more  easily  made  than  that  of 
the  former,  are  in  some  respects  even  more  instructive  for  the 
expert  in  such  work.  As  regards  the  tissue  changes  in  the 
processes  of  metabolism,  uranalysis  is  our  chief  source  of 
knowledge,  though  blood  examinations  are  always  important  in 
severe  or  doubtful  cases  of  impaired  digestion. 

You  may  object  that,  besides  rec[uiring  such  a  high  degree  of 
technical  training  in  chemistry  and  in  the  use  of  the  micro- 
scope as  not  all  general  practitioners  of  to-day  possess,  thor- 
ough analyses  of  the  urine  and  gastric  contents,  to  say  nothing 
of  chemic  and  microscopic  examinations  of  the  feces  and  blood 
counts,  consume  a  great  deal  more  time  than  patients  are  will- 
ing to  pay  for. 

Better  Fees  Should  be  Paid  for  Analyses,  etc. — It  is  doubt- 
less to  an  extent  true  that  patients  object  to  paying  for  such 
work ;  but  it  is  your  duty  as  family  physicians  to  assist  in  edu- 
cating the  laity  in  such  matters.  Most  patients  of  moderate 
means  will  pay,  without  grumbling,   handsome  fees  for  no 

143 


144  •  METHODS   OF   EXAMINATION 

more  necessary  surgical  operations,  and  they  should  be  taught 
to  pay  adequately  for  exceptional  time  and  skill  devoted  to 
indispensable,  complicated,  and  time-consuming  procedures 
which  are  performed  in  the  laboratory. 

We  physicians  by  our  zeal  in  the  cause  of  science  and  will- 
ingness to  do  certain  kinds  of  work  with  little  or  no  regard 
to  a  proper  recompense  cheapen  our  profession.  Our  surgical 
friends  are  right  to  insist  upon  a  generous  remuneration  for 
their  most  valuable  services;  and  the  lawyers,  too,  are  always 
far  better  paid  than  we  are.  When,  therefore,  you  have 
trained  yourselves  (or  been  trained)  to  do  first-class  and  most 
necessary  work  in  the  way  of  skilled  examinations  in  the  labor- 
atory and  at  the  bedside,  you  should  next  train  your  patients 
to  pay  for  it  properly.  . 

Boas,  in  his  book  on  "  Diseases  of  the  Stomach,"  has  summar- 
ized the  work  of  numerous  German  investigators  concerning 
the  relations  between  the  urine  and  the  gastric  secretion,  from 
which  it  appears  that  it  is  almost  possible  to  learn  from  a  careful 
study  of  the  former  when  an  excess  or  deficiency  of  HCl  is 
being  secreted. 

Relation  between  Urinary  Acidity  and   HCl   Secretion 

These  investigations  show  that  in  health  the  urine  is  most 
highly  acid  before  meals  and  least  acid,  or  sometimes  even 
alkaline,  after  meals  at  the  height  of  digestion,  especially  after 
a  large  meal  such  as  dinner.  When,  however,  a  deficiency  of 
HCl  is  secreted,  and  still  more  when,  owing  to  complete  atrophy 
of  the  gastric  glands  or  to  any  other  cause  there  is  a  stoppage 
of  secretion  (achylia  gastrica),  the  normal  falling  off  in  the 
acidity  of  the  urine  during  digestion  is  lessened  or  fails 
altogether. 

On  the  other  hand,  when  an  excess  of  HCl  is  secreted  by  the 
gastric  glands  the  falling  off  in  the  acidity  of  the  urine  during 
digestion  is  increased  and  marked  alkalinity  is  likely  to  appear 
instead.  If  there  were  no  other  causes  than  variations  in  the 
gastric  secretion  for  fluctuations  in  the  course  of  urinary  acid- 
ity before  and  after  meals,  the  matter  would  be  very  simple, 


THE   URINE   IN    GASTRO-INTESTINAL  DISEASE  145 

and  we  could  ascertain  from  uranalyses  at  different  times  of 
the  day  the  state  of  the  HCl  secretion  with  sufficient  exactness 
for  most  chnical  purposes. 

But  there  are  other  factors  in  the  problem  which  affect  the 
result — other  causes  of  variations  in  the  urinary  acidity 
which,  so  far,  our  most  skilled  physiologic  chemists  have  not 
been  able  tc  reckon  with  or  allow  for  with  sufficient  exact- 
ness, and,  therefore,  up  to  the  present  time,  we  cannot  ascertain 
with  any  approach  to  certainty  the  state  of  gastric  secretion 
by  uranalysis.  It  seems  probable,  though,  that  this  problem 
will  yet  be  solved,  and  that  chemists  will  one  day  be  able  so 
tQ  exclude  other  disturbing  causes  of  fluctuations  in  the  urin- 
ary acidity  that  they  can  determine  therefrom  approximately 
how  much  HCl  the  stomach  is  secreting,  or  at  least  whether 
the  secretion  is  excessive  or  deficient. 

Meanwhile,  in  any  case  of  suspected  stomach  trouble  in 
which  the  introduction  of  a  tube  is  impracticable,  you  should 
test  the  urinary  acidity  before  breakfast  and  again  two  to 
three  hours  after  dinner,  and  if  you  then  find  a  pronounced 
variation  from  the  normal  decrease  of  acidity,  and  if  this 
finding  points  in  the  same  direction  as  the  external  examina- 
tion with  the  help  of  the  Benedict  effervescence  test  described  in 
Lecture  IX.,  you  may  infer  with  probable  certainty  that  the 
state  of  the  HCl  secretion  is  as  indicated  by  that  rough  test. 

Furthermore,  in  any  case  of  unusual  importance  in  which 
the  stomach  tube  cannot  be  employed — whether  the  patient 
declines  to  swallow  it,  as  some  do,  or  any  of  the  numerous  con- 
tra-indications  for  its  introduction  are  present  (see  Lecture 
VII.) — you  may  obtain  additional  confirmatory  evidence  as  to 
the  state  of  the  HCl  secretion  by  carrying  out  the  not  difficult 
method  of  determining  the  proportion  of  chlorides  in  the  urine. 

Importance  of  Estimating  the  Chlorides. — While  the  chlo- 
rides in  the  urine  are  derived  from  the  food,  and  their  amount 
generally  bears  a  direct  relation  to  the  amount  ingested,  gastric 
activity  does  to  a  great  extent  influence  the  excretion  of  this 
important  urinary  solid.     HCl,  the  physiologists  teach  us,  is 


146  METHODS  OF  EXAMINATION 

formed  by  the  parietal  cells  from  the  chlorides  which  the 
mucous  membrane  takes  up  from  the  blood,  and  the  formation 
of  acid  ceases  if  chlorides  be  withheld  from  the  food.  Accord- 
ing to  Maly,  lactic  acid,  which  is  present  in  the  stomach,  splits 
up  the  sodium  chloride  and  forms  free  HCl.  The  base  set  free 
is  excreted  by  the  urine.  It  is  thus  evident  that  during  gastric 
digestion,  when  the  formation  of  HCl  is  going  on,  the  amount 
of  chlorides  in  the  urine  diminishes  in  direct  proportion  to 
the  amount  of  acid  formed.  While  it  is  manifestly  impossible 
to  establish  the  exact  relation  without  an  exact  knowledge  as 
to  the  amount  of  chlorides  ingested  with  the  food,  there  is,  nev- 
ertheless, a  general  post-prandial  curve  which  is  of  diagnostic 
significance.  During  digestion,  the  amount  of  chlorides  in  the 
urine  gradually  diminishes,  to  increase  again  when  digestion 
is  complete  and  absorption  commences.  In  hyperacidity  the 
diminution  of  chlorides  in  the  urine  is  marked,  and  is  gener- 
ally in  proportion  to  the  degree  of  hyperacidity.  On  the  other 
hand,  in  anacidity  or  gastric  atrophy  no  such  diminution  is 
observed.  Therefore,  if  you  determine  the  chlorides  in  the 
urine  voided  immediately  before  and  again  one  to  two  hours 
after  a  meal,  you  may  obtain  satisfactory  information  as  to 
the  probable  presence  of  hyper-  or  hypo-acidity,  provided,  how- 
ever, you  exclude  other  conditions  which  produce  fluctuations 
in  the  excretion  of  chlorides,  such  as  vomiting  and  the  forma- 
tion of  exudates.  According  to  Hemmeter,  if  a  small  amount 
of  chlorides  is  accompanied  by  an  equivalent  reduction  in  the 
amount  of  urea  excreted,  the  indications  are  that  the  case  is 
one  of  simple  inanition,  a  benign  stenosis ;  but  if  the  reduction 
of  the  chlorides  is  associated  with  a  relatively  large  amount  of 
urea,  malignant  stenosis  is  probably  present.  I  may  here 
remark  that  in  drawing  inferences  as  to  the  normal  or  increased 
excretion  of  chlorides,  you  should  always  take  into  account  the 
urea  excretion.  If  the  increase  of  chlorides  is  due  to  increased 
digestion  of  food,  the  urea  will  be  proportionately  increased, 
and  vice  versa. 

The  determination  of  chlorides  is  best  accomplished  by  the 


THE   URINE   IN    GASTRO-INTESTINAL  DISEASE  I47 

very  accurate  method  devised  by  Volhard.  The  solutions  re- 
quired are:  i.  A  standard  silver  solution  prepared  by  dissolv- 
ing 29.075  grms.  of  silver  nitrate  in  i  liter  of  water.  Each 
c.  c.  of  this  solution  equals  lo  milligrams  of  sodium  chloride. 
2.  A  saturated  solution  of  ferric  alum.  3.  A  standard  solu- 
tion of  potassium  sulphocyanid,  so  prepared  that  25  c.  c.  of  the 
solution  equal  10  c.  c.  of  the  silver  nitrate  solution. 

Having  prepared  these  solutions  yourselves,  or  obtained  them 
from  a  reliable  chemist,  you  can  make  the  determination  with 
considerable  ease.  Method :  Take  10  c.  c.  of  the  urine,  add  4 
c.  c.  of  nitric  acid  and  15  c.  c.  of  the  silver  nitrate  standard 
solution.  Dilute  the  whole  with  water  to  100  c.  c.  Filter. 
Take  80  c.  c.  of  the  filtrate,  add  5  c.  c.  of  the  ferric  alum  solu- 
tion and  titrate  with  sulphocyanid  solution  until  a  permanent 
red  color  is  imparted  to  the  mixture.  Divide  the  number  of 
c.  c.  of  sulphocyanid  solution  used  by  2  and  subtract  the 
result  from  15.  The  remainder  represents  the  number 
of  c.  c.  of  silver  nitrate  solution  required  to  precipitate  the 
chloride  in  10  c.  c.  of  urine.  As  each  c.  c.  of  silver  solution 
equals  10  mgms.,  the  number  of  c.  c.  multiplied  by  10  repre- 
sents the  number  of  mgms.  in  10  c.  c.  of  the  urine,  and  this 
again  multiplied  by  10  gives  the  amount  in  100,  or  the  per 
cent.  For  example :  Suppose  6  c.  c.  of  the  sulphocyanid 
solution  were  required  to  bring  about  the  end-reaction, 
6-f-2=3;  15 — 3=12;  12X10=120  mgms.;  120X10=1200 
mgms.,  or  1.2  grms.  per  100  (1.2  per  cent.). 

If  you  have  a  centrifuge  the  speed  of  which  can  be  regulated, 
an  electric  centrifuge  is  best,  you  may  use  Purdy's  centrifugal 
method,  which,  as  described  by  that  author,  is  performed  as 
follows :  Fill  the  graduated  tube  to  the  10  c.  c.  mark  with  the 
urine,  add  15  drops  of  nitric  acid  and  fill  to  the  15  c.  c.  mark 
with  a  standard  solution  of  silver  nitrate  ( 3  i  to  ji).  Invert 
the  tubes  several  times,  replace  into  the  centrifuge,  and  revolve 
them  at  the  rate  of  1000  revolutions  per  minute  for  three 
minutes.  The  volume  of  the  bulk  of  the  precipitate  represents 
the  percentage. 


LECTURE  XII 

THE   URINE,  CONTINUED— SIGNIFICANCE 
OF  INDICANURIA,  AND  TESTS  FOR  IT 

Partial  Examinations  of  the  Urine  Better  than  None. — To 

examine  the  urin,e  for  albumin  and  sugar  merely,  as  many  do, 
is  much  better  than  not  to  examine  it  at  all.  Even  to  take  the 
specific  gravity  and  make  the  Heller's  or  the  heat  and  nitric 
acid  test  for  albumin  may  afford  valuable  information  in  the 
management  of  a  case.  But  you  should  do  a  great  deal  more 
with  the  urine,  as  a  rule,  when  the  patient  is  chronically  out  of 
health.  For  a  high  specific  gravity  alone  by  no  means  proves 
the  presence  of  sugar,  nor  a  low  specific  gravity  renal  inade- 
quacy, and  albumin,  transiently  present  with  or  without  casts, 
does  not  necessarily  signify  Bright's  disease.  Nor  does  the 
absence  of  both  albumin  and  casts  at  a  single  examination 
exclude  the  possibility  of  diseased  kidneys.  And  the  urine  very 
often  presents  other  abnormal  conditions  which  indicate  disease 
in  other  organs  than  the  kidneys.  These  are  trite  truths  for 
experts  in  physical  diagnosis,  but  need  to  be  emphasized  for 
many  others. 

Unfortunately,  the  older  teachings  on  this  subject  were 
deficient.  A  recent  medical  writer  of  more  than  ordinary 
prominence  and  ability,  in  very  properly  calling  attention  to  the 
importance  of  more  frequent  analysis  of  the  urine,  names  the 
following  as  the  only  points  concerning  which  it  is  necessary 
in  most  cases  to  examine :  "  Quantity,  color,  clearness,  odor, 
reaction,  specific  gravity,  albumin,  sugar,  sediment."  This  list 
does  not  include  indican,  the  degree  of  acidity,  the  total  amount 
of  solids  excreted  in  twenty-four  hours,  or  even  the  amount  of 
uric  acid,  all  of  which  are  most  important. 

Indicanuria,  High  Acidity,  etc. — In  my  laboratory,  out  of 

148 


THE   URINE   IN    GASTRO-INTESTINAL   DISEASE  I49 

many  hundreds  of  urinary  analyses  made  during  the  past 
year,  fully  one-half  revealed  an  excess  of  indican.  This  indi- 
canuria  is  most  frequently  a  consequence  of  excessive  putrefac- 
tion in  the  intestines,  which  usually  indicates  more  or  less 
auto-intoxication  and  many  resulting  nervous  symptoms,  often 
of  a  serious  and  distressing  character.  It  has  also  been  ob- 
served in  unhealthy  pleuritic  exudation  and  in  peritonitis  with 
putrid  pus  (Von  Jaksch),  but  such  cases  are  very  rare  in  com- 
parison with  those  resulting  from  putrefaction  of  incompletely 
digested  proteids  in  the  bowels.  Hochsinger  has  found  that 
the  urine  of  newborn  children  is  free  from  indican,  and  that 
in  healthy  infants  it  occurs  only  in  traces.  According  to  the 
latter  observer,  "it  becomes  more  abundant  in  intestinal  dis- 
orders, and  is  always  most  so  when  these  are  attended  by 
diarrhea."  My  own  experience  fully  confirms  this  last  obser- 
vation of  Hochsinger.  The  latter  recorded  also  that  "  tuber- 
culosis, whether  affecting  the  intestinal  tract  or  not,  was  always 
accompanied  by  profuse  indicanuria." 

The  ether-sulphuric  acid  compounds  generally,  or  aromatic 
sulphates,  when  present  in  the  urine,  have  a  significance  similar 
to  that  of  indican,  and  their  percentage  should  be  determined  in 
stubborn  or  difficult  cases,  but  the  methods  of  determining  them 
are  rather  complicated — scarcely  practicable  except  in  well- 
equipped  laboratories. 

In  a  considerable  pro'portion  of  my  cases  there  has  been  also 
an  abnormally  high  total  acidity.  Patients  with  overacid 
urine  are  apt  to  be  sufferers  from  intestinal  indigestion, 
constipation,  rheumatism,  neuralgia,  headaches,  or  insomnia, 
and  often  several  of  these  ailments,  as  well  as  a  variety 
of  other  nervous  symptoms.  Not  till  the  excessively  ^cid  con- 
dition of  the  urine  has  been  relieved  by  improving  the  diges- 
tion; by  alkaline  diuretics  and  an  appropriate  diet,  including 
an  abundance  of  pure  water,  have  the  patients  made  any  sub- 
stantial improvement  in  health. 

The  falling  of  the  total  amount  of  solids  passed  by  the  kid- 
neys in  twenty- four  hours,  below  an  average  of  looo  grains 


150  METHODS    OF   EXAMINATION 

(65  grms.)  in  a  person  weighing  140  pounds  or  upwards, 
indicates  a  depression  of  the  renal  function.  If  repeated  tests 
ahvays  show  a  markedly  diminished  excretion  of  solids,  in 
spite  of  the  institution  of  measures  to  increase  it,  there  is 
reason  to  suspect  beginning  chronic  interstitial  nephritis,  even 
though  there  are  no  decided  symptoms  and  no  albumin  or  casts. 
On  the  contrary,  an  increase  in  the  solids  when  there  has  been 
no  loss  of  weight  from  wasting,  indicates  an  excessive  intake 
of  food,  which  you  should  correct. 

Uric  acid  excess  is  one  of  the  most  common  morbid  condi- 
tions that  may  be  shown  by  a  thorough  examination  of  the 
urine.  Without  going  to  the  length  that  Haig  does  in  attrib- 
uting a  very  large  proportion  of  chronic  internal  diseases  to 
this  one  excrementitious  product,  it  must  be  admitted  that  its 
presence  in  the  system  in  unusually  large  amounts  is  always 
accompanied  by  decidedly  unpleasant  and  often  by  distressing 
symptoms,  which  may  be  ultimately  dangerous  to  life,  but  we 
now  know  that  other  associated  metabolic  products,  such  as 
the  xanthin  bases,  are  the  real  toxic  agents. 

A  Quick  Test  for  Indican. — There  are  many  tests  for 
indican,  most  of  which  are  rather  complicated  to  be  serviceable 
to  the  busy  general  practitioner.  By  the  following  method, 
however,  it  is  easy  to  decide  almost  instantly  whether  there  is 
present  any  notable  excess  of  indican : 

Pour  into  a  small  test  tube  a  dram  (4  c.  c.)  of  the  strong- 
est hydrochloric  acid  and  add  about  30  drops  (2  c.  c.)  of  the 
urine  to  be  tested.  Shake  the  mixture  or  stir  with  a  glass  rod. 
If  there  should  be  a  decided  excess  of  indican,  a  purplish  blue 
or  violet  tint  will  appear  almost  immediately.  If  such  a  reac- 
tion does  not  occur  promptly,  add  i  drop  of  strong  fuming 
nitric  acid.  If  this  should  not  develop  one  of  the  above-men- 
tioned colors,  there  is  no  indicanuria ;  the  sooner  the  purple 
color  appears,  the  greater  is  the  excess  of  indican. 

Should  you  find  an  excess  of  indican  by  this  simple  qualita- 
tive test,  it  would  be  well  to  make  a  quantitative  determination. 
This  is  important,  not  only  because  it  furnishes  information 


THE   URINE   IN    GASTRO-INTESTINAL   DISEASE  I5I 

regarding  the  degree  of  indicanuria,  but  enables  you  to  judge 
from  subsequent  analyses  of  the  degree  of  improvement 
brought  about  by  treatment.  The  quantitative  tests  for  indican 
described  in  the  more  elaborate  text-books  are  entirely  too  com- 
plicated for  ready  application,  but  the  method  devised  by  Dr. 
A.  Robin  is  both  simple  and  accurate.  As  described  by  him  in 
the  International  Medical  Magazine  (December,  1900),  the 
test  is  performed  as  follows : 

"  Approximate  Quantitative  Test  for  Indican. — Prepare  the 
following  solutions :  ( i )  Obermeyer's  reagent,  which  is  made 
up  of  strong  hydrochloric  acid,  C.  P.  and  2  grms.  of  ferric 
chloride  for  each  1000  c.  c.  of  the  acid;  (2)  a  25  per  cent, 
solution  of  lead  acetate;  (3)  a  solution  of  potassium  chlorate 
containing  i  per  cent,  of  available  CI  or  34.6  grms.  of  the 
salt  per  liter. 

"To  10  c.  c.  of  the  urine  add  i  c.  c.  of  the  lead  acetate  solu- 
tion and  filter  through  a  double  filter.  Put  5  c.  c.  of  the  filtrate 
into  a  test  tube,  add  5  c.  c.  of  Obermeyer's  reagent  and  2  c.  c. 
of  chloroform  and  invert  the  test  tube  about  ten  times,  or  until 
the  color  of  the.  chloroform  ceases  to  become  more  intense. 
The  latter  will  assume  a  violet  or  blue  color,  according  to  the 
amount  of  indican  present.  Now  add  from  a  dropper  the 
potassium  chlorate  solution,  drop  by  drop,  shaking  the  mixture 
after  each  addition  until  the  blue  color  of  the  chloroform  dis- 
appears. The  potassium  chlorate  liberates  chlorine  in  the 
presence  of  a  strong  mineral  acid  and  oxidizes  the  indigo 
formed  by  the  addition  of  Obermeyer's  reagent.  If  the 
amount  of  indican  is  normal,  one  or  two  drops  will  cause  dis- 
coloration. In  making  your  memoranda,  mark  down  '  dis- 
colored by  X  drops  of  K  CIO 3  solution.'  This  will  give  you 
exact  information  as  to  the  increase  or  decrease  of  indican  in 
a  given  case. 

"  The  advantages  of  this  method  over  similar  ones  are:  (i) 
A  special  oxidizer  is  used  for  converting  the  indican  into  indigo. 
(2)  There  is  no  danger  of  carrying  the  oxidation  beyond  the 
point  of  the  appearance  of  indigo,  as  is  the  case  when  the 


152  METHODS   OF   EXAMINATION 

chlorine  solutions  are  used,  since  ferric  chloride  does  not  oxi- 
dize the  indigo  formed.  ( 3 )  By  employing  potassium  chlorate 
instead  of  the  chlorides,  we  have  a  permanent  solution  of 
definite  strength  which  is  easily  prepared.  (4)  The  final 
oxidation  of  the  indigo  introduces  a  fixed  point  far  more  ac- 
curate than  the  intensity  of  the  coloration  of  the  chloroform 
upon  which  most  of  the  other  methods  depend.  (5)  The 
determination  can  be  made  in  a  few  minutes,  only  small 
quantities  of  urine  being  required." 

Test  for  the  Total  Amount  of  Solids. — A  rough  and  hasty, 
but  sufficiently  accurate  way  of  estimating  the  total  amount  of 
solids  excreted  by  the  kidneys  in  twenty-four  hours  is  as 
follows : 

Have  all  the  urine  passed  from,  say  8  a.  m.  one  day  to 
7  a.  M.  the  next  saved,  measured,  and  the  number  of  ounces 
noted.  Then  multiply  the  number  of  ounces  by  the  last  two 
figures  that  represent  the  specific  gravity  of  a  sample  out  of 
the  entire  collected  urine  and  add  to  the  product  one-tenth  of 
itself.  For  example,  if  50  ounces  of  urine  were  passed  in  the 
aggregate  during  one  day  and  night  and  the  specific  gravity 
of  a  sample  taken  out  of  the  collection  were  1020,  this  would 
be  the  calculation : 

50X20  =  1000.  Then,  adding  one-tenth  of  1000  ^100 
would  make  iioo,  representing  approximately  the  number  of 
grains  of  solid  matters  excreted.  This  would  be  normal  for 
a  person  weighing  from  130  to  140  pounds.  Those  weighing 
less  or  more  should  excrete  relatively  less  or  more  solids. 
After  middle  age  the  ratio  of  excretion  is  usually  found  some- 
what diminished. 


LECTURE   XIII 

THE  URINE,  CONCLUDED  — TESTS  FOR 
URIC  ACID,  UREA,  AND  THE  ACIDITIES 
—  LABORATORY   OUTFIT 

Tests  for  Uric  Acid. — As  to  uric  acid,  a  copious  deposit  of 
red  sand  in  the  vessel  in  which  urine  has  stood  for  three  or 
four  hours  only,  points  usually  to  excessive  excretion  of  this 
substance,  though  a  very  decided  acidity  of  the  urine  from 
other  causes,  such  as  abundant  fermentation  in  the  gastro- 
intestinal tract,  or  a  marked  scantiness  of  the  urine,  may  lead 
to  such  a  large  precipitation  of  uric  acid  even  when  only  a 
moderate  proportion  of  it  is  being  excreted.  The  lower 
powers  of  the  microscope  will  also  reveal  a  great  number  of 
uric  acid  crystals  under  the  same  conditions. 

The  following  method  of  Heintz  gives  fairly  reliable  results 
for  clinical  purposes. 

Take  200  c.  c.  of  urine,  and  add  to  it  10  c.  c.  of  strong 
HCl.  Let  it  stand  for  twenty-four  hours  (better  forty-eight 
hours)  in  a  cool  room.  Collect  the  precipitated  uric  acid 
crystals  on  a  previously  weighed  filter,  and  wash  with  cold 
distilled  water.  Dry  the  filter  and  uric  acid  crystals  in  a 
desiccator  (or  it  will  dry  in  a  few  hours  in  any  warm  place), 
and  weigh.  By  subtracting  the  weight  of  the  filter,  the  result 
will  be  the  weight  of  the  uric  acid  in  200  c.  c.  of  urine.  If 
albumin  be  present,  it  should  first  be  removed  and  the  urine 
should  always  be  filtered  before  applying  the  test,  otherwise 
subsequent  filtration  is  very  difficult. 

Ruheman's  Method  of  Determining  the  Amount  of  Uric 
Acid  by  Means  of  the  Uricometer. — An  instrument  has  been 
devised  by  Dr.   J.    Ruheman  of   Berlin   for  the   quantitative 


154  METHODS    OF    EXAMINATION 

estimation  of  uric  acid.     It  is  easily  manipulated  by  any  one, 
and  yet  quite  accurate.     The  solutions  needed  are  as  follows : 

A.  Carbon  bisulphide. 

>.  B.   Iodine Grms.  1.5 

Potass,  iodide "       1.5 

Alcohol  strong C.  c.  15.0 

Distilled  water C.  c.  185.0 

The  urine  to  be  tested  must  be  acid;  if  not,  add  acetic  acid. 
Cloudiness  is  of  no  importance.  Fill  the  uricometer  to  the 
mark  S  with  the  carbon  bisulphide;  add  the  solution  B  up 
to  the  mark  J,  and  then  add  the  urine  to  be  tested  up  to  the 
mark  2.45  (2.6  c.  c.  m.) ;  close  the  tube  and  shake  well.  The 
carbon  bisulphide  will  become  dark  brown.  Add  more  urine 
little  by  little,  shaking  the  mixture  after  each  addition  until 
the  foam  is  white.  The  CSo  will  now  be  a  light  pink.  Shake 
vigorously,  and  if  the  pink  color  does  not  disappear,  add  a 
few  drops  more  of  urine  and  shake  vigorously  again.  Con- 
tinue this  until  the  CSo  turns  a  porcelain  white.  The  pro- 
portion of  uric  acid  per  1000  is  read  off  on  the  right  hand 
scale. 

Urea. — This  is  the  normal  end  product  of  nitrogenous  me- 
tabolism and  in  amount  it  should  be  about  one-half  that  of  the 
total  solids.  Various  gastro-intestinal  affections  and  also 
the  diet  vary  its  rate  of  excretion.  The  determination  of 
urea  is  best  accomplished  by  means  of  Doremus'  modified 
ureometer.  Ten  c.  c.  of  a  saturated  solution  of  sodium  hy- 
drate are  put  in  the  bulb-end  of  the  tube  and  i  c.  c.  of  bromine 
added.  Care  should  be  exercised  in  taking  up  the  bromine, 
as  it  is  extremely  irritating  and  corrosive.  When  the  reaction 
between  the  bromine  and  sodium  hydrate  is  complete,  as  may 
be  judged  from  the  entire  disappearance  of  the  former, 
enough  of  water  is  added  to  fill  the  closed  end  of  the  tube 
up  to  a  little  above  the  bend.  When  the  formation  of  gas 
bubbles  has  all  subsided  the  apparatus  is  freed  from  the  latter 
by  inclining  it.  and  the  side  tube  is  filled  with  water  to  the 
zero  mark.  One  c.  c.  of  urine  is  then  carefully  discharged 
into  the  hypobromite  solution  and  the  apparatus  set  aside  until 


THE   URINE   IN    GASTRO-INTESTINAL   DISEASE  1 55 

complete  evolution  of  gas  has  occurred.  The  volume  of  gas 
in  the  closed  end  of  the  ureometer  indicates  the  amount  of 
urea  in  i  c.  c.  of  urine. 

Test  for  the  Total  Acidity. — Determining  the  degree  of 
acidity  or  amount  of  total  acidity  in  urine  is  a  simple  pro- 
cedure. It  requires  merely  an  inexpensive  burette,  or  long 
glass  tube  graduated  to  tenths  or  fifths  of  a  cubic  centimeter, 
a  graduated  cubic  centimeter  measure  and  a  small  glass  cup 
or  beaker  holding  two  to  four  ounces.  There  are  required 
also  a  one-tenth  normal  (decinormal)  solution  of  caustic 
soda  and  a  one  per  cent,  alcoholic  solution  of  phenolphtha- 
lein.  Partly  fill  the  burette  with  the  soda  solution  and  note 
down  the  reading  or  exact  figure  opposite  the  upper  limit  of 
the  solution,  and  for  this  purpose  it  is  the  rule  to  consider 
the  bottom  rather  than  the  top  of  the  curve  which  liquid 
always  assumes  in  a  tube  at  its  upper  end.  Measure  out  and 
place  in  the  glass  receptacle  lo  c.  c.  of  the  urine  and  add 
to  it  one  or  two  drops  of  the  phenolphthalein.  Then  add, 
drop  by  dro]3,  the  soda  solution  from  the  burette  until  the 
red  color  thus  produced  no  longer  disappears  upon  shaking. 
A  uniform  pale  red  color  will  now  tinge  the  entire  lo  c.  c. 
of  urine,  indicating  that  the  acidity  of  the  latter  is  about 
neutralized.  Then  read  the  burette  again  and  subtract  the 
figure  from  that  first  obtained,  multiply  the  remainder  by  lo, 
and  the  product  is  the  total  acidity.  In  the  absence  of  a 
burette  with  its  lower  end  so  arranged  as  to  allow  the  escape 
of  the  contents  drop  by  drop,  one  may  get  on  quite  well  by 
first  placing  a  measured  amount  of  the  soda  solution  in  any 
receptacle,  and  then  taking  up  in  an  ordinary  rubber-topped 
pipette  and  dropping  out  of  this  into  the  measured  urine  so 
much  of  the  soda  solution  as  is  necessary  to  neutralize  the 
former  completely  in  the  same  manner  described  above. 
When  this  has  been  accomplished,  the  remaining  test  solution 
will  need  to  be  measured  again  and  the  difference  between 
the  two  measurements  multiplied  by  lo  will  be  the  figure 
representing  the  total  acidity. 


156  METHODS    OF    EXAMINATION 

For  example,  suppose  that  to  begin  with,  there  was  in  the 
burette  or  other  receptacle  20.2  c.  c.  of  the  soda  solution,  and 
after  the  titration  (as  the  whole  process  is  called)  there  are 
16. 1  c.  c.  left.  Subtracting,  it  is  found  that  4.1  c.  c.  of  the 
solution  have  been  used.  Multiplying  these  figures  by  10 
(since  10  c.  c.  of  urine  were  used  and  all  such  calculations 
are  upon  the  basis  of  100  cubic  centimeters)  we  have  41  as 
the  total  acidity. 

Important  as  this  test  is  to  gauge  the  degree  of  acidity  of 
the  system  generally  and  prevent  the  blood  from  becoming 
too  feeblv  alkaline,  it  has  been  so  little  practiced  that  there  is 
not  yet  by  any  means  an  agreement  among  different  observers 
as  to  the  normal  acidity  of  the  urine;  but,  judging  by  my 
own  by  no  means  small  experience,  it  is  safe  to  put  it  at 
between  20  and  30.  A  wide  departure  from  these  limits  in 
either  direction  threatens  an  impairment  of  the  health  if  long 
continued,  when  it  does  not  indicate  an  im.pairment  already 
established. 

Freund  and  Topfer's  Test  for  the  Urinary  Acidities. — 
Freund  and  Topfer  suggest  the  following  method,  which 
furnishes  more  complete  data  concerning  the  acidity  of  the 
urine:  To  10  c.  c.  of  the  urine  add  2  to  4  drops  of  a  i  per 
cent,  solution  of  alizarin.  If  the  resulting  color  is  pure 
yellow,  free  acids  are  present;  if  deep  violet,  combined  acid 
salts.  If  none  of  these  colors  appear,  there  are  present  acid 
salts  and  alkaline  salts  of  the  type  of  disodicphosphate.  The 
amount  of  one-tenth  normal  HCl  standard  solution  recpired 
to  produce  a  pure  yellow  color  represents  the  alkaline  salts, 
while  the  amount  of  one-tenth  normal  sodium  h)^drate  required 
to  cause  a  deep  violet  tint  represents  the  acid  salts. 

Biliary  Pigments  and  Acids. — AMienever  there  is  obstruc- 
tion to  the  fiow  of  the  bile  into  the  bowel  there  will  be  found 
more  or  less  of  the  bile  pigments  and  acids  in  the  urine.  It  is 
said  they  may  be  recognized  in  the  urine  even  before  the  ap- 
pearance of  jaundice  or  the  slightest  change  in  the  con- 
junctivae.    Since  disorders  of  the  stomach  and  liver  go  hand 


THE   URINE   IN    GASTRO-INTESTINAL   DISEASE  1 57 

in  hand  so  very  frequently,  it  is  highly  important  to  test  the 
urine  for  such  substances  in  all  obscure  or  doubtful  cases. 
The  bile  pigments  may  be  revealed  by  the  familiar  Gmelin's 
test  described  in  all  the  books,  and  there  are  many  others,  but 
one  of  the  simplest  of  the  good  ones  is  Ultzmann's,  which  is 
thus  carried  out:  Mix  with  lo  c.  c.  of  the  urine  3  or  4  c.  c. 
of  concentrated  caustic  potash  solution  and  acidify  with  HCl. 
When  the  bile  pigments  are  present  the  urine  will  then  turn 
a  beautiful  green  color  which  is  very  striking. 

A  very  easy  and  sensitive  test  for  the  bile  acids  has  been 
devised  by  Hay.  It  is  said  not  to  respond  to  any  substance  to 
be  found  in  the  urine  except  the  bile  acids.  The  urine  should 
be  cooled  to  17°  C.  (about  63°  F.)  or  less,  and  placed  in  a  small 
glass  beaker.  On  the  surface  is  then  sprinkled  a  little  finely 
powdered  sulphur.  If  bile  acids  are  absent,  the  sulphur  will 
not  sink;  if  present  in  a  proportion  of  1-10,000,  it  will  sink  at 
once  without  having  been  shaken.  If  1-40,000  is  present,  it 
will  sink  after  gentle  shaking  for  one  minute.  Ultimate  sink- 
ing will  occur  if  the  bile  acids  are  present  in  the  proportion  of 
1-120,000. 

An  excess  of  bile  acids  in  the  urine  points  to  some  important 
hepatic  derangement.  They  may  occur  not  only  as  a  result 
of  obstruction  of  the  bile  ducts,  but  also  in  consequence  of 
congestion  or  cirrhosis  of  the  liver  and  in  various  diseased 
conditions,  including  carcinoma  or  other  tumors  of  the  liver, 
and  in  severe  bilious  attacks.  The  combination  of  hepatic 
cirrhosis  or  congestion  with  constipation  will  often  produce  an 
excess  of  the  bile  acids  in  the  urine.  Thus  something  may 
frequently  be  learned  by  testing  for  these  acids ;  yet,  ordinarily, 
testing  for  the  bile  pigments  will  determine  with  sufficient  ac- 
curacy the  presence  of  bile  in  the  urine. 

Acetone  and  Diacetic  Acid. — Not  only  in  diabetes  and  in 
certain  fevers,  but  also  in  the  opposite  conditions  of  starvation 
and  an  excessive  meat  diet  can  acetone  be  found  in  the  urine. 
It  is  also  frequently  present  in  carcinoma  and  sometimes  in 
other    cachectic   conditions    such    as    mav    arise    in    extensi\'e 


158  METHODS    OF    EXAMINATION 

dilatation  of  the  stomach.  When,  therefore,  you  desire  to 
exhaust  every  means  of  reaching  an  approximately  accurate 
diagnosis  in  a  doubtful  case  you  should  test  for  acetone;  and 
in  order  not  to  be  misled  by  the  possible  presence  of  diacetic 
acid,  which  by  decomposition  often  forms  acetone,  you  should 
first  test  for  diacetic  acid  by  the  v.  Jaksch  method  as  folloWs : 
Add  to  the  urine  a  concentrated  solution  of  perchloride  of  iron 
cautiously,  drop  by  drop.  If  a  phosphatic  precipitate  falls, 
filter  this  off  and  add  a  few  drops  of  the  iron  solution.  If  now 
a  red  color  appears,  boil  a  portion  of  the  urine,  w-hich  by  the 
Avay  should  have  been  freshly  voided,  and  to  another  portion 
add  a  few  drops  of  sulphuric  acid  and  shake  with  ether.  If 
the  boiled  urine  shows  no  reaction  with  the  iron  solution  and 
the  ethereal  extract  develops  a  claret-red  color  with  that  solu- 
tion, diacetic  acid  is  probably  present  and  should  be  removed 
from  the  sample  to  be  tested  for  acetone,  though  most  works 
on  uranalysis  make  no  mention  of  this  important  fact.  Its 
removal,  according  to  Charles  F.  Martin,^  is  effected  by  render- 
ing the  urine  faintly  alkaline  and  then  shaking  it  carefuVy  in  a 
separator  funnel  with  ether.  The  latter  should  be  free  from 
both  alcohol  and  acetone.  The  removed  ether  must  then  be 
shaken  with  water,  which  takes  up  the  acetone,  and  this  watery 
solution  of  the  purified  acetone  may  then  be  tested  for  the 
latter. 

Lichen's  Iodoform  Test  for  Acetone  is  the  one  generally 
recommended,  though  there  are  numerous  other  substances 
often  in  the  urine  which  produce  a  similar  reaction,  and  when 
accuracy  is  desired  it  is  best  to  distill  the  urine  and  test  the 
distillate.  The  test  is  then  carried  out  as  follows :  Dissolve 
20  grains  of  potassium  iodide  in  a  dram  of  liquor  potassse, 
and  boil.  The  urine  is  then  floated  on  the  surface  of  the 
licjuid  in  a  test  tube.  At  the  point  of  contact  a  precipitation 
of  iodoform  occurs.  Even  when  a  distillate  of  the  urine  is 
used  for  the  test,  the  presence  of  lactic  acid  or  ethyl  alcohol 
in  it  may  produce  similar  reactions. 

^Wood's  "  Reference  Handbook,"  Revised  Ed.  vol.  i.  p.  66. 


THE   URIXE   IN    GASTRO-INTESTIXAL   DISEASE  159 

Diacetic  acid  is  never  present  in  urine  in  the  absence  of 
acetone,  and  its  presence  with  the  latter  signifies,  according  to 
most  authorities,  a  serious  condition  in  the  case  of  adults, 
usually  portending  in  diabetics  the  approach  of  coma.  In 
children  it  is  a  frequent  accompaniment  of  fever  and  not  neces- 
sarily important. 

Dr.  Robin,  in  an  article  written  at  my  request  for  the  Inter- 
national Medical  Maga:::ine,  advised  as  follows : 

"  For  the  purpose  of  collecting  the  urine  and  determining 
the  amount,  a  graduated  bottle  is  the  only  suitable  vessel.  The 
ordinary  way  of  collecting  the  urine  in  a  night-pot  introduces 
a  considerable  error  in  the  specific  gravity  by  the  constant 
evaporation  to  which  the  urine  is  subjected  in  an  open  or 
imperfectly  closed  vessel.  Any  ordinary  bottle  of  a  capacity  of 
2000  c.  c.  (one-half  gallon)  can  easily  be  graduated  by  means 
of  a  long  strip  of  paper  pasted  on  the  outside,  with  marks 
corresponding  to  divisions  of  500  c.  c.  each.  If  the  night- 
pot  is  the  only  container  available,  the  patient  should  be  in- 
structed to  deposit  a  layer  of  vaselin  on  the  under  surface  of 
the  lid  where  it  comes  in  contact  with  the  upper  edge  of  the 
pot.  The  amount  can  be  measured  either  by  means  of  a 
glass  (usually  of  eight  ounces'  capacity)  or  a  beer  bottle 
(which  contains  about  one  pint).  In  the  case  of  the  busy  man 
who  is  away  from  home  during  the  day,  he  can  be  instructed 
to  carry  about  him  two  flat  bottles  (eight  ounces  each)  into 
which  he  urinates  as  occasion  demands  and  upon  reaching  his 
house  he  empties  them  into  the  general  container." 

To  the  foregoing  valuable  suggestion  it  should  be  added  that 
the  vessel  in  which  the  urine  is  to  be  collected  should  be  care- 
fully scalded  before  used  and,  during  the  collection,  a  wet 
cloth  be  kept  over  it  in  order  to  keep  it  as  cool  as  possible  and 
prevent  decomposition.  The  addition  of  preservatives  cannot 
be  advised,  since  most  of  them  interfere  with  the  chemical 
examination.  For  example,  a  specimen  containing  formalm 
will  not  react  to  the  test  for  indican  and  chloral  hydrate  will 
give  a  positive  reaction  with  Fehling's  solution. 


LECTURE  XIV 

THE  EXAMINATION  OF  FECES— THE 
BLOOD  IN  GASTRO-INTESTINAL  DIS- 
EASES 

A\'ere  it  not  for  the  offensive  odor  of  the  feces,  the  examina- 
tion of  them  by  the  general  practitioner  would  probably  be  as 
common  as  that  of  urine.  But  neither  excretion  is  studied  cis 
much  as  it  should  be.  The  data  which  may  be  obtained  from 
an  examination  of  feces  are  as  important  from  a  diagnostic 
standpoint  as  those  obtained  from  an  uranalysis.  The  feces 
represent  in  health  the  total  of  whatever  material  passes  unab- 
sorbed  through  the  gastro-intestinal  tract.  In  disease,  it  con- 
tains admixtures  of  morbid  material,  the  presence  of  which 
may  of  itself  often  be  sufficient  to  establish  a  positive  diagnosis 
of  either  some  gastro-intestinal  derangement  or  actual  disease. 

In  view  of  the  valuable  information  that  may  be  gained  in 
this  way,  it  would  seem  incumbent  on  the  physician  to  over- 
come the  natural  repugnance  to  this  malodorous  excretion  and 
resort  to  an  examination  of  the  feces  whenever  indicated  by 
reason  of  obscure  gastro-intestinal  symptoms.  Let  me  here 
remind  you  that  the  fecal  odor  may  be  successfully  masked  by 
covering  the  feces  with  a  thin  layer  of  ether. 

The  Feces  in  Health. — In  health  the  contents  of  the  small 
intestines  are  liquid.  As  they  reach  the  large  intestine  they 
are  propelled  with  less  rapidity,  and  in  their  comparatively 
slow  course  through  the  descending  colon  and  sigmoid  flexure 
lose  a  considerable  amount  of  water,  which  is  absorbed.  In 
consequence,  the  feces  assume  a  semisolid  consistency  and  are 
molded.  W'ithin  certain  limits,  the  consistency  and  form  of 
the  feces  will  vary  even  in  health,  the  variation  depending  on 

i6o 


THE    EXAMINATION    OF    FECES^    ETC.  l6l 

the  amount  and  character  of  the  food  and  the  degree  of  peri- 
stalsis. It  is  weh  to  note  in  this  connection  that  the  ingestion 
of  even  large  amounts  of  water  does  not  influence  much  the 
consistency  of  the  fecal  mass,  though  it  does  somewhat,  and 
a  deficiency  of  ingested  fluids  may  be  one  cause  of  constipation. 
The  quantity  passed  in  twenty- four  hours  is  about  100-200 
grms.  The  fecal  odor  is  due  to  indol  and  skatol,  substances 
which  are  the  result  of  bacterial  action  on  the  undigested 
organic  matter.  The  color  is  a  yellowish-brown  and  is  pro- 
duced by  bilirubin,  which  is  the  coloring  matter  derived  from 
altered  bile.  The  reaction  is  usually  alkaline,  but  may  be 
acid. 

The  Macroscopic  Examination. — The  fecal  discharges  may 
be  examined  separatel}-,  or  the  twenty-four  hours'  excretion 
collected  in  a  closed  vessel  to  which  some  formalin  has  been 
added.  The  formalin,  of  course,  should  be  omitted  when  a 
bacteriologic  investigation  of  the  feces  is  intended. 

The  feces,  if  semisolid,  should  be  diluted  with  water  and 
stirred  into  a  uniform  fluid  mass.  In  this  should  be  noted 
the  color,  reaction,  and  the  admixture  of  unusual  elements. 

The  Color. — A  dark  pitch-like  appearance  is  produced  by 
the  action  of  the  gastric  juice  on  mucus,  blood,  and  epithelium. 
This  appearance  will  sometimes  characterize  the  feces  during 
starvation  or  fasting, — always  wdien  there  has  been  hemor- 
rhage from  the  stomach  or  upper  intestine  and  the  altered 
blood  appears  in  the  stools.  A  yellowish-gray  color  is  due 
to  mucus  when  in  large  quantity.  The  presence  of  a  yellow- 
colored  serum  indicates  a  large  amount  of  pus.  A  straw- 
colored  serum  occurs  in  cholera.  A  blood-like  color  is  pro- 
duced by  huckleberries,  and  sometimes  by  beets,  while  a  green- 
ish or  blackish  color  is  due  to  the  sulphides  of  mercury  or  bis- 
muth. A  blackish-gray  color  is  produced  by  the  sulphide  of 
iron,  the  sulphides  of  these  metals  being  formed  by  the  action 
of  hydrogen  sulphide  present  in  the  intestines.  A  yellow  color 
is  produced  by  rhubarb,  senna,  and  santonin.  After  the  admin- 
istration of  methylene  blue,  a  bluish-green  color  will  appear  on 


1 62  METHODS    OF   EXAMINATION 

the  exposure  of  the  feces.  A  green  color  may  also  be  pro- 
duced by  certain  chromogenic  bacteria.  A  clay  color  is  due  to 
excess  of  fat  (undigested)  or  absence  of  bilirubin.  The  pres- 
ence ^f  unaltered  bile-pigment  is  always  an  indication  of 
disease. 

In  the  past  few  years  great  advance  has  been  made  in  the  ex- 
amination of  the  feces  by  Prof.  Adolph  Schmidt.  He  has  de- 
vised a  test  diet  which,  under  normal  conditions,  gives  a  prac- 
tically uniform  stool. 

Schmidt's  Test  Diet  consists  of  five  meals  per  day  and,  as 
this  is  at  variance  with  American  customs,  Roberts  of  New 
York  has  modified  it  slightly  so  as  to  conform  to  our  habits. 
This  modification,  with  the  caloric  value  of  each  article,  is  as 
follows : 

For  Breakfast  calories 

A  teacupful  of  well-strained  oatmeal i6o 

A  tablespoonf ul  of  cream 80 

A  teaspoonful  of  sugar 40 

Lean  meat,  finely  chopped,  broiled  rare,  an  amount  equal 

to  a  heaping  teaspoonful 60 

Three  slices  of  toast  (4x4x5^  inch  thick) 150 

An  inch  cube  of  butter    65 

A  large  glass  of  milk  (8  oz.) 160 

At  Midday 

Potato  puree  ( i  potato  to  8  oz.  milk) 225 

A  slice  of  toast,  size  as  above 50 

A  half-inch  cube  of  butter 30 

Lean  meat  as  above,  a  teacupful  in  amount 150 

Add  an  inch-cube  of  butter , 65 

One  large  well-baked  potato 75 

Add  two  teaspoonfuls  of  cream  or  a  ^-inch  cube  of 

butter 40 

Two  slices  of  bread,  size  as  above 100 

An  inch  cube  of  butter 65 

A  large  glass  of  milk 160 


THE    EXAMINATION    OF    FECES,    ETC.  163 

For  Slipper  calories 

A  teaspoonful  of  rice,  cooked  dry 150 

Add  an  inch  cube  of  butter 65 

Two  poached  eggs 140 

Three  shces  of  bread 150 

An   inch   cube   of  butter 65 

A  large  glass  of  milk 150 

This  gives  a  diet  which  consists  of:  proteid,  100  grams;  fat, 
80  grams;  and  carbohydrates,  300  grams.  The  total  caloric 
value  is  about  2,400. 

This  test  diet  is  given  until  a  stool  is  passed,  which  cer- 
tainly comes  from  this  diet,  which  is  usually  the  second  or 
third  stool  after  the  beginning  of  the  diet.  No  charcoal  or 
carmine  powder  is  necessary  to  demark  the  stool,  as  the  latter 
is  sufhciently  characteristic  to  enable  one  to  distinguish  it 
without  difficulty.  The  color  is  light  and  the  consistency  is 
uniform.  At  times  we  may  find  that  some  patients  cannot 
take  milk  either  because  it  produces. an  indigestion  or  causes 
constipation.  In  such  cases  one-third  of  the  milk  may  be 
cooked  with  the  food,  and  the  other  may  be  boiled  with  cocoa 
or  chocolate. 

As  soon  as  the  characteristic  stools  appear,  one  should  be 
passed  directly  into  a  clean  screw-topped  glass  jar  and  sent 
immediately  to  your  office  for  examination.  The  examination 
should  be  made  while  the  feces  are  as  fresh  as  possible.  The 
color,  consistency,  and  odor  should  be  noted.  Then  stir  up  the 
feces  thoroughly  with  a  horn  or  wooden  spatula,  and  place  a 
portion  about  the  size  of  a  walnut  in  a  glass  mortar.  Grind  it 
with  the  glass  pestle  as  thoroughly  as  possible,  adding  about  a 
teaspoonful  of  distilled  water  at  a  time  until  it  is  of  fluid  con- 
sistency. This  is  then  poured  out  into  a  shallow  glass  ves- 
sel or  over  a  black  plate  in  a  very  thin  film.  Schmidt  says : 
"  In  normal  digestion  there  ought  to  appear  very  few  brown 
points  (smaller  than  pinheads),  chaffy  remains  of  the  oat- 
meal gruel,  perhaps  remains  of  cocoa  nibs,  the  nature  of  which 
is  ultimately  explained  by  microscopic  investigation." 


164  METHODS    OF    EXAMINATION 

When  the  patient  has  eaten  fruit,  berries,  etc.,  before  this 
test  diet,  we  may  find  their  remnants,  seeds,  etc.,  in  the  stool. 
These  often  grate  on  rubbing.  Larger  crystals  of  triple  phos- 
phates which  you  so  often  find  in  the  stool  may  also  grate  under 
the  pestle. 

Under  pathological  conditions  we  may  be  able  to  detect  with 
the  unaided  eye  (1)  mucus,  (2)  remains  of  the  connective 
tissue  or  tendon  fibers  of  the  meat,  or  (3)  pieces  of  muscle,  or 
(4)  potato,  and,  finally,  of  (5)  large  crystals  of  triple  phos- 
phates. 

Small  bits  of  mucus  are  easily  detected  by  placing  a  little  of 
the  feces  on  a  piece  of  window  glass  and  held  up  against  the 
light.  It  then  appears  as  glassy  transparent  flakes  sometimes 
stained  yellowish  by  bile  pigment.  Large  masses  of  mucus 
can  scarcely  be  overlooked,  but  at  times  they  may  have  mixed 
in  with  them,  many  epithelial  cells  or  fat  bodies,  and  may  lose 
the  characteristic  glassy  appearance  so  familiar  to  you  all. 
Then  the  appearance  may  resemble  very  much  a  tapeworm,  as 
mentioned  in  Lecture  LXXX.,  when  speaking  of  intestinal 
parasites:  or  the  mistake  may  be  made  of  thinking  them  to  be 
the  lining  of  the  intestine.  In  case  of  doubt  they  should  be 
submitted  to  the  microscopic  test  presently  to  be  described. 
The  greater  part  of  the  mucus  found  in  the  stool  comes  from 
the  large  intestine ;  that  coming  from  the  small  intestine  is  in- 
timately mixed  with  the  feces  and  is  in  very  fine  pieces.  The 
more  numerous  the  cells  (leucocytes,  round  cells,  etc.)  in  the 
mucus,  the  greater  is  the  degree  of  inflammation. 

The  bits  of  connective  tissue  and  tendon  fibers  are  distin- 
guished from  the  mucus  by  their  yellowish  color,  greater  con- 
sistency, and  threadlike  appearance.  They  can  also  be  recog- 
nized by  microscopic  examination,  as  I  shall  subsequently  ex- 
plain. They  can  often  be  found  under  normal  conditions,  but 
if  numerous  and  large,  they  indicate  a  disturbance  of  gastric 
digestion,  for  Schmidt  has  demonstrated  that  raw  connective 
tissue  is  digested  only  by  the  gastric  juice. 

Under  normal  digestion  with  this  diet  there  should  be  prac- 


THE    EXAMINATION    OF    FECES,    ETC.  165 

tically  no  meat  fibers  visible.  If  seen  with  the  naked  eye,  they 
indicate  disturbances  of  intestinal  digestion. 

Potato  remains  exist  under  normal  digestion  only  as  empty 
cells.  If  larger  fragments  are  present,  staining  blue  when  a 
little  Lugol's  solution  is  added,  derangement  of  starch  digestion 
is  indicated. 

Large  crystals  of  ammonio-magnesium  phosphate  (triple 
phosphates)  occur  only  in  putrefying,  malodorous  stools. 

Microscopic  Examination. — We  usually  supplement  the 
naked-eye  appearances  by  examining  portions  of  the  stool 
microscopically.  In  this  examination,  we  proceed  as  follows : 
Place  a  drop  of  the  fluid  stool  in  the  center  of  a  slide  and  one 
at  either  end.  Over  one  drop  place  a  cover  glass  and  press  it 
down  firmly,  without  adding  anything  to  the  feces.  To  a  sec- 
ond drop  add  a  small  drop  of  acetic  acid  (30%),  heat  for  a 
moment  over  the  flame  until  it  begins  to  boil,  and  then  place 
over  it  a  cover  glass.  To  the  third  drop  of  feces  add  a  small 
drop  of  Lugol's  solution  (Iodine  i,  KI  2,  Aq.  Dest.  50),  and 
stir  with  a  small  glass  rod,  and  finally  place  over  it  a  cover 
glass.  In  the  first  drop  (without  addition)  we  see,  under  the 
microscope,  detritus,  bacteria,  and  other  minute  bodies,  and 
also  some  larger  bodies,  which  consist  (i)  of  muscle  fibers. 
These  are  yellowish  in  color  (stained  by  bile)  and  normally 
show  no  striation.  If  these  muscle  fibers  are  numerous,  and, 
further,  if  the  striations  are  seen  under  the  1-6  inch  objective, 
they  indicate  derangement  of  digestion  in  the  small  intestine. 
(2)  Yellow  salts  of  calcium  and  colorless  soaps.  (3)  Isolated 
potato  cells.  (4)  Chaffy  remains  of  the  oatmeal  and  of  cocoa. 
In  the  drop  treated  with  acetic  acid,  we  see,  after  cooling, 
small  flakes  of  fatty  acid.  If  examined  while  hot  we  see  drops 
instead  of  the  flakes.  In  the  third  drop  treated  with  iodine  we 
find  potato  hulls  which,  under  normal  digestion,  stain  violet, 
but  if  starch  digestion  is  interfered  with,  we  see  dark  blue  (al- 
most black)  starch  granules. 

Even  with  the  test  diet  some  fat  is  normally  found  in  the 
stool,  so  that  the  only  criterion  is  the  amount  of  fat  appearing. 


1 66  METHODS   OF   EXAMINATION 

(i)  Excessive  amounts  appear  in  deficiency  of  bile,  in  which 
case  the  subHmate  test  is  negative,  i.e.  the  feces  are  not  turned 
red  by  a  solution  of  corrosive  sublimate;  (2)  in  deficient  ab- 
sorption of  fat  by  a  deranged  small  intestine;  and  (3)  with 
faulty  pancreatic  secretion  or  absence  of  the  pancreatic  juice. 
In  the  latter  case  we  find  drops  of  neutral  fat  and  also  many 
large  muscle  fibers. 

Schmidt  says :  "  Defective  starch  digestion  has  its  seat  in  the 
small  intestine.  It  depends  for  the  most  part  upon  a  dis- 
turbance of  the  intestinal  juices,  and,  in  the  absence  of  any 
other  alteration  in  the  condition  of  the  feces,  does  not  signify 
any  serious  disturbance." 

As  is  well  known,  it  very  often  signifies  merely  excessive  in- 
gestion of  starch  and  deficient  mastication,  particularly  in  per- 
sons with  a  tendency  to  hyperchlorhydria. 

Chemical  Examination. — In  testing  the  reaction  of  the  feces, 
which  normally  should  be  neutral  or  at  least  amphoteric  (i.e. 
turn  blue  litmus  red  and  red  litmus  blue),  we  place  a  strip  of 
litmus  paper  o>i  (not  in)  the  feces,  which  have  been  rubbed 
up  with  distilled  water. 

A  very  important  test,  according  to  Schmidt,  is  the  sublimate 
test.  To  carry  this  out  3'ou  place  a  small  amount  of  the  feces 
which  have  been  rubbed  up  with  water  in  a  glass  containing  a 
saturated  solution  of  corrosive  sublimate  (bichloride  of  mer- 
cury) and  allow  this  to  stand  until  the  next  day.  The  normal 
stool  is  colored  red  (indicating  hydrobilirubin).  Particles 
stained  green  are  pathologic  and  consist  of  unchanged 
bile. 

Fermentation  Tube. — Another  important  chem'ical  test  is 
performed  by  means  of  Strasburger's  fermentation  tube,  which 
can  easily  be  improvised  by  reference  to  Fig.  32  on  engraved 
plate  inserted  at  the  end  of  this  lecture.  In  the  lower  bottle 
is  placed  a  portion  of  the  feces  (as  it  comes  to  you)  about  the 
size  of  a  walnut.  Add  water  and  stir,  and  shove  the  rubber 
stopper  in  until  no  air  bubble  remains.  The  rubber  stopper  is 
taken   from  the  little  tube  "  b  "  and  the  tube  filled  with  tap 


THE    EXAMINATION    OF    FECES^    ETC.  167 

water.  This  is  then  closed  by  putting-  on  the  stopper  with  the 
vessel  connected  with  it,  "  a  "  (filled)  and  "  c  "  (empty)  ;  "  c  " 
has  an  opening  in  top.  Then  place  the  apparatus  in  an  in- 
cubator (at  body  temperature)  or  in  a  warm  place,  and  leave 
for  24  hours.  If  gas  develops  from  the  feces,  it  collects  in 
"  a  "  or  "  b,"  and  a  corresponding  amount  of  water  is  driven 
into  "  c."  The  height  of  the  water  in  "  c  "  is  noted,  and  the 
reaction  of  contents  of  "  c  "  is  taken  with  litmus  paper  and 
compared  with  the  reaction  of  the  fresh  feces. 

Normally  only  a  very  little  gas  is  formed,  and  the  reaction 
is  unchanged.  If  the  tube  "  c  "  is  more  than  one-third  full  of 
water  at  the  conclusion  of  the  test,  then  pathologic  conditions 
are  present.  Further,  if  the  reaction  has  become  distinctly 
more  acid,  the  fermentation  is  caused  by  carbohydrates;  if,  on 
the  other  hand,  the  reaction  is  distinctly  more  alkaline,  the 
cause  of  the  gas  is  albuminous  putrefaction  as  pointed  out  by 
Schmidt.  If  carbohydrate  fermentation  has  occurred,  the  gas 
has  the  odor  of  butyric  acid  (rancid  butter),  and  the  color  is 
lighter;  if  albuminous  putrefaction,  there  is  putrefactive  odor 
and  the  color  is  darker. 

Various  Foreign  Substances  to  be  Looked  For. — Even  in 
normal  feces  berries,  fragments  of  potatoes  and  apples,  and 
shreds  of  fibrous  tissue  may  be  present.  After  the  ingestion 
of  oranges,  the  pulp  and  cells  may  be  present,  and  the  latter 
have  been  frequently  mistaken  for  parasites,  to  which  they  bear 
some  resemblance. 

In  intestinal  catarrh  the  feces  may  contain  epithelium  and 
cylindric  shreds  or  membranous  pieces  or  strings  of  mucous 
membrane. 

Gall  stones  are  frequently  present  in  the  stools  of  patients 
suffering  from  hepatic  colic.  They  should  be  looked  for  in 
every  case  of  that  affection. 

Intestinal  parasites  are  frequently  present,  and  search  should 
he  made  for  them  in  every  case  in  which  their  presence  is 
suspected.  A  brief  description  of  the  more  important  of 
these  will  be  found  in  Lecture  LXXX. 


1 68  METHODS   OF   EXAMINATION 

The  presence  of  blood  indicates  hemorrhage,  and  most  fre- 
quently ulceration  somewhere  in  the  tract. 

In  the  feces  of  an  individual  on  ordinary  diet  many  sub- 
stances are  often  found  which  may  be  confounded  with  intes- 
tinal parasites.  The  general  practitioner  should  be  constantly 
on  his  guard  against  such  mistakes,  and  should  familiarize 
himself  with  the  gross  and  microscopical  picture  of  such  sub- 
stances. The  spines  from  raspberries  have  been  mistaken  for 
hookworm.  In  a  famous  case  several  pathologists  mis- 
took for  a  parasite  what  Virchow  demonstrated  to  be  simply 
the  skin  of  an  apple.  In  another  instance  reported  to  me, 
the  spiral  fibers  so  often  found  in  vegetables,  especially 
bananas,  caused  a  grave  error  in  diagnosis.  In  rare  instances, 
the  eggs  of  flies,  especially  the  blow  fly,  may  have  been  de- 
posited on  the  food.  These  eggs  will  develop  in  the  intestinal 
tract  into  the  larvae,  or  maggots,  and  as  such  be  passed  with 
the  stool. 

Crystals. — In  the  feces  are  found  usually  crystals  of  triple 
phosphates  of  coffin-lid  shape,  such  as  we  so  frecjuently  find 
in  decomposed  urine.  Besides  these,  there  often  occur  the 
needle-formed  crystals  of  the  free  fatty  acids.  These  latter 
can  be  easily  recognized  by  adding  a  drop  of  i  per  cent,  al- 
coholic solution  of  Sudan  III,  which  colors  them  orange  to 
blood  red.  Cholesterine,  which  rarely  occurs  in  the  typical 
crystalline  form,  can  be  readily  recognized  by  adding  a  drop 
of  concentrated  sulphuric  acid,  which  gives  them  a  red  violet 
green  and  finally  a  blue  color.  Bismuth  oxide  crystals  seen 
after  the  exhibition  of  bismuth  subnitrate,  occur  in  black  ir- 
regular rhombic  shape.  Charcot-Leyden  crystals  are  color- 
less, double  diamond  shaped,  and  always  indicate  some  form 
of  intestinal  parasite. 

Vegetable  parasites.  It  is  not  expected  that  the  general 
practitioner  will  have  the  time,  skill,  or  ecjuipment  to  make 
cultures  from  feces  for  the  purpose  of  identifying  the  several 
specific  micro-organisms,  as  the  B.  typhosus,  B.  cholerae,  B. 
dysenterise,  and  others.     Yet,  a  mere  microscopic  examination 


Fig.  27. — I.  A,  G,  aspergillusglaucus;  M,  M,  mucor  mucedo;  O,  L,  oidium 
lactis;  S,  C,  saccharomyces  cerevisise.  2.  S,  P,  Staphylococcus  pyogenes; 
G.gonococcus;  jM,  T,  micrococcus  tetragenes;  D,  P,  diplococcus  pneumo- 
niae. 3.  S,  P,  Streptococcus  pyogenes;  S,  F,  sarcina  flava;  B,  T,  bacillus 
typhosus;  B,  A,  L.  bacillus  acidilactici.  4.  B,  S.  bacillus  subtilis;  B,  C, 
bacillus  coli  communis;  B,  A,  bacillus  anthracis;  B,  T,  bacillus  tuber- 
culosis. 5.  V,  C,  vibrio  cholerce;  B,  T.  bacillus  tetani;  B,  D,  bacillus 
diphtherise;  S,  S,  spirillum  serpens.  6.  Spiroch  spirochaste;  Sp.,  spirilli 
from  nasal  mucus;  A,  B,  actinomyces  bovis;  S,  F,  P,  spirillum  of  Fink- 
ler  and  Prior. 


170 


METHODS   OF    EXAMINATION 


of  stained  specimens  is  of  little  value  since  bacteria  cannot,  as 
a  rule,  be  identified  by  their  morphology  alone.  In  the  accom- 
panying illustration  are  shown  the  more  important  pathogenic 
micro-organisms,  and  it  may  be  clearly  seen  that  while  we 
are  ;  always  able  to  distinguish  by  shape  and  form  cocci 
from  bacilli,  or  the  latter  from  spirilli,  we  are  unable  to  differ- 


FiG.  28. — a,  tufts  of  fat  needles  ("  arranged  in  tufts  ").  b,  crystals  of  am- 
monio-magnesium  phosphates  (triple  phosphates)  on  the  right  hand; 
calcium  oxalate  on  the  left;  underneath,  rudimentary  forms,  c,  choles- 
terin-plates.  d,  Charcot-Leyden  crystals,  e^  particles  of  animal  char- 
coal (given  for  the  purpose  of  fixing  the  limits  of  the  feces).  (From 
"  Klinik  der  Verdauungskrankheiten,"  von  Prof.  Dr.  C.  A.  Ewald.) 

entiate  the  pathogenic  from  the  saprophytic  micro-organisms  of 
the  same  group  without  further  study  by  means  of  culture  and 
even  animal  experiments. 

There  is,  however,  one  exception,  the  tubercle  bacillus. 
Owing  to  the  characteristic  staining  reaction  of  this  micro- 
organism, its  presence  may  be  detected  in  the  feces  by  mere 
microscopic  examination  of  a  properly  stained  specimen.  In 
examining  the  feces  for  tubercle  bacilli  it  is  preferable  to  select 
particles  of  mucus,  as  they  are  more  likely  to  contain  the  bacilli. 


THE    EXAMINATiUN    OF    FECES^    ETC. 


171 


It  has  been  suggested  to  produce  constipation  by  the  administra- 
tion of  opiates,  and  then  select  for  examination  whatever  sHmy 
particles  adhere  to  the  outside  of  the  fecal  mass.  This  sugges- 
tion is  based  on  the  assumption  that  the  hard  fecal  mass,  in 
passing  through  the  bowels,  will  carry-  from  the  tubercular 
ulcer  whatever  particles  may  become  detached.  It  is  to  be 
noted  that  the  examination  for  tubercle  bacilli  in  the  feces,  in 


Fig.  29. — Stool  in  chronic  colitis,  a,  triple  phosphates,  b,  cocci  and  bac- 
teria. ^,  vegetable  cells  (beans?),  (i',  Clostridium  butyricum.  <?,  muscle- 
fibers.  /",  needles  of  fatty  acids,  g,  spiral  vessel  from  a  plant,  h, 
starch-granules,  i,  disintegrated  remains  of  muscle-fibers.  At  the 
center  are  the  bright,  highly  refractive  drops  of  mucus.  (From  "  Klinik 
der  Verdauungskrankheiten,"  von  Prof.  Dr.  C.  A.  Ewald.) 

cases  of  intestinal  tuberculosis,  is  often  disappointing.  It  is 
advisable  to  make  several  preparations,  and  at  frequent  inter- 
vals, in  case  of  negative  results.  It  is  now  claimed  that  the 
bacilli  are  present  in  the  stools  of  practically  all  cases  of  gen- 


172 


METHODS   OF   EXAMINATION 


eral  and  pulmonary  tuberculosis.     The  method  of  preparation 
and  staining  is  the  same  as  in  the  case  of  sputum. 


Fig.  30. — a,  crystals  of  bismuth  sulphid.  b,  fat-droplets  consisting  of 
neutral  fat  (glistening  brightly)?  c,  zooglea  masses,  containing  diplo- 
cocci,  tetracocci,  and  bacilli,  d,  hyphomycetes.  e,  j^east-cells.  _/,  spirals 
of  vegetable  vessels.  (From  "  Klinikder  Verdauungskrankheiten,"  von 
Prof.  Dr.  C.  A.  Ewald.) 


Illustrations  of  Microscopic  Findings  in  Feces. — The  fig- 
ures on  pp.  170-172,  and  also  on  the  plate  found  at  the  end  of 
this  chapter,  illustrate  the  exact  appearance  under  the  micro- 
scope, of  slides  prepared  from  feces.  While  the  majority  of 
the  things  represented  in  them  are  of  little  diagnostic  im- 
portance, it  is  well  to  be  able  to  recognize  them  and  differenti- 
ate them  from  more  significant  objects. 


THE    EXAMINATION    OF    FECES^    ETC.  1/3 

The  last  of  these  three  photomicrographs  represents  numer- 
ous objects  of  interest,  and  some  of  decided  diagnostic  signifi- 
cance. 

THE   BLOOD   IN   GASTRO-INTESTINAL   DISEASES 

A  large  amount  of  study  has  been  devoted  to  the  condition 
of  the  blood  in  most  of  the  diseases  that  affect  mankind — the 
more  important  affections  of  the  alimentary  tract  especially. 
Scores  of  investigators  in  various  parts  of  the  world  have 
sought  to  find  in  blood  changes  points  to  help  in  establishing 
the  diagnosis  of  ulcer  and  of  carcinoma  of  the  stomach  particu- 
larly, and  frequently  the  claim  has  been  made  that  results  of 
decisive  value  in  this  direction  have  been  achieved.  But  later 
the  reliability  of  such  discoveries  has  been  disputed  and  usually 
disproved.  Eventually  more  useful  results  will  likely  follow 
from  this  line  of  research. 

Blood  Examinations  Not  Conclusive  in  Stomach  Cases. — 
Without  entering  here  into  any  extended  account  of  the  con- 
troversies upon  this  subject,  it  is  enough  to  assure  you  that  up 
to  the  present  time  even  the  most  careful  and  painstaking  ex- 
aminations of  the  blood  as  to  the  number  and  character  of  its 
red  cells,  white  cells,  hemoglobin,  and  other  constituents,  of 
the  bacteria  and  parasites  in  it,  and  even  determinations  of  its 
specific  gravity  and  alkalinity,  have  not  afforded  us  much 
trustworthy  assistance  in  reaching  a  diagnosis  in  doubtful 
gastro-intestinal  cases. 

Blood  examinations  can  scarcely  be  expected  to  decide  posi- 
tively the  diagnosis  in  any  case  in  which  a  serious  stomach 
disease  could  be  suspected,  though  in  a  few  intestinal  diseases 
and  possibly  some  painful  gastric  conditions  which  might  be 
confounded  with  lead  colic,  a  blood  examination  may  often 
help  clear  up  the  doubt.  I  do  not  mean,  however,  to  disparage 
the  importance  of  the  vast  amount  of  research  done  in  hema- 
tology. It  has  been  miost  fruitful  of  good  results  in  deter- 
mining the  diagnosis  of  typhoid  fever,  malaria,  and  various 
other  diseases,  and  has  added  much  to  our  knowledg"e  of  the 


1/4  METHODS   OF  EXAMINATION 

deteriorating  effect  of  most  gastro-intestinal  diseases  upon  the 
blood. 

Interesting  observations,  too,  have  been  made  by  Henry '  of 
Philadelphia  concerning  the  state  of  the  blood  in  gastric  can- 
cer. He  has  shown  that  in  the  latter  disease  the  red  corpuscles 
never  fall  below  1,500,000,  while  in  every  fatal  case  of  perni- 
cious anaemia  they  will  be  found — at  the  last — under  1,000,000 
per  cubic  millimeter.  He  sums  up  the  results  of  his  investiga- 
tions in  this  field  by  stating  that  "  the  diminution  in  the  num- 
ber of  red  blood  cells  in  carcinoma  of  the  stomach  does  not 
keep  pace  with  the  cachexia ;  in  pernicious  anemia  the  cachexia 
does  not  keep  pace  with  the  oligocytha^mia." 

These  are  very  important  observations,  and  may  sometimes 
help  you  to  decide  in  an  obscure  case,  yet,  manifestly  the  find- 
ing of  1,500,000  red  cells  in  the  blood  of  a  weak,  cachectic,  and 
emaciated  patient  could  scarcely  be  decisive. 

In  suspected  pernicious  anaemia  dependent  upon  gastric  atro- 
phy, there  would  be  an  absence  of  free  HCl  and  might  be 
gastric  pain  independent  of  eating  as  in  cancer,  and  the  fact 
that  at  the  last  the  number  of  red  blood  cells  might  in  such  a 
case  fall  500,000  lower  than  they  could  in  cancer,  would  hardly 
establish  the  diagnosis — at  least  not  long  before  the  autopsy, 
which  would  afford  much  more  conclusive  evidence.  In  any 
such  doubtful  case,  the  complete  absence  of  the  gastric  fer- 
ments would  make  strongly  for  the  diagnosis  of  anaemia  from 
atrophy,  while  the  presence  of  large  amounts  of  mucus  with 
much  decomposing  food  remains  as  well  as  the  Boas-Oppler 
bacilli  and  a  decided  percentage  of  lactic  acid,  would  more  likely 
indicate  cancer,  and  such  findings  as  these  would  be  more  de- 
cisive than  even  considerable  differences  in  the  proportion  of 
erythrocytes  in  the  blood,  or  the  always  difficultly  determinable 
degree  of  cachexia. 

But,  though  blood  counts  and  hemoglobin  estimations  can 
rarely  settle  a  doubtful  diagnosis  where  a  digestive  trouble 
is  involved,  they  can  help  much  in  determining  the  extent  to 
'  "  Archiv.  d.  Verdauungskrankh.,"  vol.  iv.  Heft  I. 


THE    EXAMINATION    OF    FECES_,    ETC.  175 

which  such  troubles  have  lowered  the  health  of  your  patients. 
They  can  also  afford  valuable  evidence  of  the  progress  the 
latter  are  making  toward  recovery. 

The  most  frequent  cause  of  persistent  anjemia  and  chlorosis 
is  believed  to  be  found  in  autotoxsemia,  or  auto-intoxication 
from  various  diseases  of  the  digestive  system.  Cancer  and 
ulceration  often  add  hemorrhage  as  a  further  direct  cause  of 
anaemia,  but  these  are  infrequent  as  compared  with  the  dis- 
placements, dilatations,  and  catarrhal  inflammations  which 
lead  to  imperfect  digestion,  stagnation,  constipation,  and  other 
chronic  causes  of  blood  impoverishment. 

Frequent  blood  counts  and  estimations  of  the  hemoglobin 
should,  therefore,  not  be  neglected  in  managing  the  important 
diseases  of  the  digestive  system. 

Below  are  brief  descriptions  of  some  of  the  simplest  and 
most  satisfactor}^  methods  of  making  the  more  necessary 
examinations  of  the  blood : 

To  Obtain  a  Specimen  of  Blood. — The  necessary  specimen 
of  blood  is  best  obtained  from  the  lobe  of  the  ear,  but  the 
finger-tip  is  more  commonly  selected  as  the  part  to  be  punc- 
tured. The  puncture  is  made  with  a  rather  large  bayonet- 
tipped  aseptic  needle,  or  a  specially  devised  blood  lancet. 

After  thoroughly  cleansing  the  lancet  and  site  of  the  pro- 
posed puncture  with  alcohol  or  ether  followed  by  sterile  water, 
the  part  is  wiped  perfectly  dry  and  held  firmly  while  the  oper- 
ator with  a  rapid  wrist  motion  makes  a  puncture  of  sufficient 
size  to  cause  several  drops  of  blood  to  flow  freely.  This  should 
always  be  allowed  to  flow  of  its  own  accord,  the  operator  being 
careful  not  to  squeeze  the  part  and  thus  dilute  the  blood  with 
lymph  from  the  surrounding  tissue,  which  would  give  rise  to 
an  error  in  the  result. 

The  first  one  or  two  drops  coming  from  the  puncture  should 
be  discarded,  after  which  a  perfectly  clean  cover-glass  is 
applied  to  the  next  drop  of  blood  as  it  oozes  out.  The  cover- 
glass  is  at  once  placed  blood  side  downward  upon  a  perfectly 
clean  glass  slide.    A  thin  film  of  blood  should  be  obtained  as  a 


176  METHODS    OF   EXAMINATION 

result  of  this  contact  made  in  the  presence  of  shght  heat  and 
without  pressure. 

An  excellent  smear,  in  which  the  corpuscles  are  disposed  in 
a  vary  uniform  manner,  can  be  made  by  touching  a  fresh  drop 
of  blood  with  the  flat  surface  of  a  clean  slide  and  applying  the 
edge  of  another  slide  held  somewhat  obliquely  to  the  drop. 
Wait  till  the  blood  has  run  along  the  edge,  then  drag  the  edge 
of  the  slide  along  so  as  to  make  an  even  film.  Dry  and  fix 
either  by  heat  for  two  minutes  at  160°,  or  by  equal  parts  of 
ether  and  alcohol,  or  by  formalin  vapor. 

The  Technique  of  the  Examination. — The  specimen  can 
now  be  stained  and  examined  under  a  microscope  with  both 
high  and  low  powers  in  a  moderate  light  for : 

1.  Changes  in  the  number  and  condition  of  the  red  cells. 

2.  Changes  in  the  number  and  condition  of  the  w^hite 
cells. 

3.  Increase  in  blood  plaques. 

4.  Presence  of  parasites  and  foreign  bodies. 

In  gastro-intestinal  cases  you  will  rarely  need  to  carry  your 
examinations  beyond  i  and  2. 

Blood  Counts. — If  it  becomes  necessary  to  make  an  exact 
count  of  the  red  and  white  cells,  many  methods  and  instru- 
ments have  been  devised  to  carry  out  the  procedure.  The  in- 
struments of  Thoma-Zeiss  and  Gowers  are,  however,  still 
considered  to  be  among  the  best. 

The  Thomas-Zeiss  hemocytometer  consists  of  two  gradu- 
ated capillary  pipettes  for  diluting  and  mixing  the  blood  and 
a  chamber  in  which  is  placed  a  definite  portion  of  the  diluted 
blood  for  the  purpose  of  counting  the  corpuscles  under  the 
microscope.  One  pipette  is  used  for  collecting  and  diluting  the 
blood  to  count  the  red  cells  and  another  for  collecting  and 
diluting  the  blood  to  be  used  in  counting  the  white  cells. 

To  count  the  red  blood  cells  the  blood  is  drawn  up  in  the 
pipette  to  the  mark  i  and  the  diluent  (which  may  be  a  normal 
salt  solution,  roughly,  oi  to  Oi)  added  until  the  mark  loi  is 
reached.     This  makes  a  dilution  of  i  to  100.     If  the  blood  is 


^-'g-  JJ- 


(LtiU.  ObJ.  7.) 


cL^= 


C.  ---\A-V-- 


\>  b. 


/vC".  j/a 


/ieila,  ObJ.  7  J 


IMjr. 


I'i 


•'K- 


•51.    Microscopic  Appearaxce   of  Normal  Test-Diet  Feces.     ' 

a    Muscle-remains.  d.  Chaffy  remains.  f  Detritus 

.:  Soajr  '    """'  '""'•  "•  ^'"P'y  P°t^*°  «"«•  '^.  Cocoa  re„>ai„s. 

•a,;.     Microscopic  Appearance  of  Pathologic  Ingredie.nts  in  the  Test- 
Diet  Feces  (Combined  Picture).  • 

^  Fat?v  a'dcU  «nfr'^^.T"'';,,  '''  S^^^'"'^*'  '^'^^""'«  ">  Potato  cells. 

Neut^raT  at  '^  S=  Granuliferous  Clostridia  and  hyphomycetes. 

tiii.diidi.  y;  Yeast  cells. 

•;i(^.     Fermentation  Tubes  (Dr.  Strasburger). 

( /v'ow  ' •  Tlir  Tr,l-ni^f  a,  Intcsdnal  Diseases  ''—Schmidt  and  Aaron.) 


THE    EXAMINATION    OF    FECES^    ETC.  1/7 

drawn  only  to  the  mark  0.5  and  the  diluent  added  as  before,  a 
dilution  of  i  to  200  is  obtained. 

After  mixing  the  blood  in  the  bulb  of  the  pipette,  it  is 
put  on  the  glass  slide  containing  a  counting  chamber.  A  dilu- 
tion of  I  to  200  is  preferable  to  make  an  easy  count  and  avoid 
crowding  the  blood  cells  in  the  squares. 

The  counting  chamber  is  ruled  into  400  small  squares  sep- 
arated into  groups  of  16  squares  by  double  lines.  The  surface 
of  a  square  is  i -400th  of  a  square  millimeter,  and  the  depth 
of  the  cell  being  one-tenth  millimeter,  the  space  overlying  each 
square  is  i -4000th  of  a  cubic  millimeter. 

The  number  of  corpuscles  counted  in  all  the  squares  is  mul- 
tiplied by  400,  and  the  result  by  the  dilution,  i  :ioo  or  i  :200 
depending  upon  the  point  to  which  the  blood  was  drawn  in  the 
pipette,  I  or  0.5. 

This  result  is  divided  by  the  number  of  squares  counted,  and 
the  final  result  is  the  number  of  corpuscles  in  a  cubic  millimeter 
of  blood. 

In  counting  the  zvhite  blood  cells  a  0.5  per  cent,  solution  of 
acetic  acid  is  used,  which  dissolves  the  red  cells  and  renders  the 
white  cells  more  prominent. 

A  dilution  of  i  :io  is  made  by  drawing  the  blood  up  in  the 
tube  to  the  mark  i  and  adding  the  diluent  to  the  mark  11.  The 
leucocytes  are  then  counted  in  an  area  of  the  counting  chamber 
equal  to  800  small  squares,  and  the  calculation  made  as  before. 
For  example,  if  120  leucocytes  were  counted  in  800  squares 
the  result  would  be  determined  as  follows:  120 X 4000 x 
io-r-8oo=  the  number  of  leucocytes  per  c.  mm. 

To  Estimate  the  Hemoglobin. — In  estimating  the  percent- 
age of  hemoglobin  in  a  given  specimen  of  blood  we  have  again 
many  instruments  to  select  from.  Talquist's  hemoglobin  scale 
is,  however,  the  instrument  most  preferred.  This  consists  of 
a  color  scale  with  a  book  of  bibulous  paper.  The  paper  is 
touched  with  a  drop  of  the  blood  and  partly  dried.  The  re- 
sulting color  is  then  compared  with  those  on  the  scale.  Fur- 
ther detailed  directions  accompany  the  scale. 


178  METHODS   OF   EXAMIXATIOX 

A  capillary  pipette  is  applied  to  a  drop  of  blood  and  then 
quickly  washed  in  one  of  the  two  compartments  of  the  mixing 
chamber.  Both  compartments  are  then  filled  with  water  to 
the  brkn,  care  being  taken  not  to  mix  the  water  from  one  com- 
partment with  that  in  the  other.  By  moving  the  graduated 
slide  a  comparison  of  color  is  made  and  the  reading  taken. 

Another  excellent  apparatus  for  the  purpose,  which  econo- 
mizes time,  is  that  of  Dare.  It  consists  of  a  capillary  chamber 
filled  directly  from  the  blood  drop,  a  color  scale,  and  a  source 
of  light  approximately  constant  in  character  and  intensity;  a 
candle  in  a  darkened  room  answers  well.  The  readings  of 
this  apparatus  are  slightly  higher  than  those  from  others,  but 
allowance  has  been  made  for  this. 

Various  Diseased  Conditions  that  may  be  Diagnosed  by  the 
Blood. — Lead  colic  has  been  mistaken  for  gastralgia,  the  pain 
of  gastric  ulcer  or  cancer,  for  hepatic  colic,  intestinal  colic,  and 
for  intestinal  obstruction  especially.  An  examination  of  the 
blood  should  prevent  such  an  error  by  revealing  the  basophilic 
granulations  in  the  red  corpuscles  Avhich  are  nearly  always 
present  in  lead-poisoning. 

Acute  abscesses  (when  non-tubercular)  in  the  appendix,  or 
in  the  abdomen  anywhere  (or  anywhere  in  the  body,  as  a 
rule)  are  likely  to  produce  a  leucocytosis  of  15,000  or  more. 

Appendicitis.  According  to  Cabot^  in  acute  appendicitis  the 
development  of  gangrene  or  general  peritonitis  is  almost  invari- 
ably accompanied  by  a  rise  of  leucocytes  to  upwards  of  20,000. 

Intestinal  obstruction  develops  within  a  few  hours  a  rapid 
increase  in  the  number  of  leucoc)i;es,  which  reaches  usually 
20,000  by  the  end  of  twenty-four  hours,  Avhen  the  obstruction 
is  complete.  When  it  is  partial  only,  the  leucocytosis  will  be 
in  proportion,  ^^^hen  gangrene  of  an  intestinal  loop  sets  in, 
the  leucocytes  may  reach  25,000  or  30,000  except  when  it 
results  from  an  infarct  of  the  superior  mesenteric  artery. 

Intestinal  parasites,  especially  hookworm,  usually  cause  a 
marked  increase  in  the  eosinophiles. 

1  "  Am.  Text-Book  of  Surgery,"  Philadelphia,  1903. 


LECTURE  XV 
A    SYMPTOMATIC    GUIDE    TO    DIAGNOSIS 

For  the  inexperienced  practitioner  especially,  and  at  times 
for  any  physician  however  experienced,  it  should  be  a  great 
convenience  to  have  at  hand  a  list  of  the  various  diseases  or 
symptom-groups  which  the  prominent  symptoms  encountered 
might  signify.  I  have  therefore  carefully  prepared  the  follow- 
ing tabular  statement  including  the  leading  symptoms  of 
gastro-intestinal  affections  with,  placed  opposite  to  each,  as 
full  a  summary  as  possible  of  the  diseases  or  other  conditions 
which  have  been  known  to  cause  it.  I  cannot  claim  these  lists 
to  be  exhaustive,  but  you  will  find  them  to  contain  certainly 
most  of  the  possible  causes  of  each  symptom. 


SYMPTOMS 


Anorexia,  or  impaired  ap- 
petite. 


Breath,  fetor  of,    or  foul 
taste  in  mouth. 


POSSIBLE    CAUSES 

Fevers  and  most  acute  diseases  ;  cancer  ;  tu- 
berculosis ;  anger  or  any  powerful  emotion  ; 
worry  ;  anxiety  ;  fright;  hysteria  ;  dyspepsia, 
especially  the  atonic  form  ;  achylia  gastrica  ; 
hypochlorhydria,and  exceptionally  HCl  excess; 
epidemic  influenza ;  chloro-anaemia  ;  diseases 
attended  with  suppuration  ;  alcoholism  ;  pro- 
longed insomnia  ;  any  wasting  or  depressing 
form  of  disease  ;  neurasthenia  ;  gastritis  ;  ca- 
tarrhal inflammation  of  any  mucous  membrane 
in  the  gastro-intestinal  tract,  or  of  the  bile 
ducts. 

Local  inflammations  or  ulcerations  of  gums, 
tongue,  tonsils,  pharynx  or  nasopharynx  ;  re- 
tention in  the  mouth  of  decomposing  food  ;  ca- 
ries of  teeth  ;  stomatitis  ;  pyorrhea  ;  retro- 
pharyngeal abscess  ;  gastroduodenal  catarrh  ; 
jaundice  ;  certain  foods  and  drugs  ;  certain 
lung  diseases,  as  tubercular  cavity,  gangrene 
or  bronchiectasis  ;  diabetes  mellitus  ;  reten- 
tion of  stomach  contents  from  atonic  dilatation 


179 


i8o 


METHODS    OF   EXAMINATION 


Bulimia,  or  excessive  ap- 
petite. 


Constipation. 


of  stomach,  pyloric  stenosis,  or  pylorospasm  ; 
cancer  of  the  stomach,  esophagus,  or  any  part 
of  oral  cavity  or  upper  air  passages  ;  scurvy  ; 
necrosis  of  jawbone  ;  constipation  ;  acute  ex- 
anthems  ;  acute  infectious  diseases  ;  anaemia; 
abscess  of  sublingual  or  submaxillary  gland  ; 
leucoplakia. 

Insufficient  mastication  ;  obstruction  of  tho- 
racic duct  ;  gastric  hyperacidity  (hyperchlor- 
hydria);  gastric  ulcer  ;  acid  gastritis  ;  diabetes; 
epilepsy  ;  various  psychoses  ;  hysteria  ;  neu- 
rasthenia ;  insanity  ;  idiocy  ;  tumor,  or  other 
affection  of  the  brain  ;  Addison's  disease  ;  tu- 
berculosis ;  syphilis  ;  Basedow's  disease  ;  preg- 
nancy ;  disease  of  the  uterus;  chronic  gastritis; 
chronic  enteritis  ;  gastrectasis  ;  pertussis  ; 
worms  ;  exceptionally  carcinoma  ;  exophthal- 
mic goitre  ;  after  starvation  ;  convalescence 
from  fevers  or  other  acute  diseases. 
Insufficient  food  ;  lack  of  coarse  foods,  vege- 
tables, or  fruits  ;  movable  kidney  or  the  down- 
ward displacement  of  any  abdominal  organ  ; 
hyperchlorhydria ;  pj^lorospasm,  or  any  ob- 
struction of  the  pylorus  ;  negligence  as  to  regu- 
larity in  time  of  going  to  stool  ;  insufficient 
mastication ;  exceptionally,  deficient  gastric 
secretion  ;  lack  of  exercise  ;  deficiency  of  bile  ; 
weakened  musculature  of  gastric,  intestinal, 
or  abdominal  walls  ;  excessive  horseback  rid- 
ing, as  in  cavalrymen  ;  prolonged  sweating  or 
polyuria  ;  chronic  pancreatitis;  hernia;  cancer 
of  esophagus  or  stomach  or  any  portion  of 
the  intestines  ;  fissure  or  fistula  in  ano  ;  per- 
sistent Meckel's  diverticulum  ;  stricture  or 
obstruction  in  any  part  of  the  alimentary 
canal;  hemorrhoids  ;  rectal  ulcer  ;  prostatitis; 
tender  or  displaced  uterus,  or  ovary  ; 
pyosalpinx  ;  deranged  innervation,  as  in 
nervous  diseases,  especially  irregular  or 
spasmodic  contractions  of  intestinal  muscles  ; 
neurasthenia  ;  hysteria  ;  anaemia  ;  peritonitis  ; 
appendicitis  ;  chronic  portal  congestion  ;  abuse 
of  purgatives  ;  the  administration  of  iron,  lead, 
opium,  or  any  astringent  ;  cerebral  congestion; 
meningitis  ;  tumor  of  brain  or  other  cerebral 
diseases  ;  adhesions  of  coils  of  intestine  to 
each  other,  or  to  neighboring  structures  ;  vol- 


A    SYMPTOMATIC    GUIDE    TO    DIAGNOSIS 


I8I 


Debility. 


Defecation,  painful. 


Discolorations  of  the  skin 
— jaundice  or  bronzing. 


Diarrhea. 


vulus,  partial  or  complete  ;  intussusception, 
acute  or  chronic  ;  the  acute  stage  of  nearly  all 
fevers  and  general  infections,  with  the  excep- 
tion of  typhoid  fever  ;  pelvic  abscess  ;  preg- 
nancy ;  tumors  pressing  upon  the  intestines. 
Carcinoma  ;  neurasthenia  ;  vomiting  or  diar- 
rhea ;  chronic  gastritis  or  enteritis ;  under- 
feeding ;  syphilis  ;  tuberculosis ;  malaria  ; 
achjdiagastrica  ;  confinement  to  bed  ;  depress- 
ing drugs,  or  overdosing  with  any  drugs  ;  any 
acute  illness  or  exhausting  disease  ;  obstruc- 
tion of  thoracic  duct  ;  any  severe  infection. 
Hemorrhoids  ;  cancer  of  rectum  ;  rectal  ulcer  ; 
fissure  or  fistula  in  the  anus  ;  proctitis  or  any 
disease  of  rectum  ;  disease  of  any  of  the  pelvic 
organs  accompanied  by  sensitiveness  to  pres- 
sure ;  caries  of  the  sacral  spine  ;  tenderness  of 
the  sacral  spine  or  coccyx  from  any  cause  ; 
prostatitis  or  ovaritis. 

Yellow  fever  ;  gastric  dilatation  ;  gastric  ulcer; 
habitual  constipation  ;  pregnancy  ;  cancer  ; 
tuberculosis  of  abdominal  viscera  ;  pernicious 
anaemia  ;  disease  of  the  liver  or  bile  ducts  ; 
exophthalmic  goiter  ;  acetanilid  poisoning, 
causing  a  slate  color  ;  tinea  versicolor  ;  syphil- 
itic eruptions  ;  scleroderma  ;  extension  of  gas- 
troduodenitis  to  gall  bladder  and  ducts  ;  tox- 
aemia; any  obstruction  to  flow  of  bile,  as  from  a 
neighboring  tumor  or  displaced  kidney;  Addi- 
son's disease;  mental  emotion;  acute  infectious 
diseases;  argyria  ;  acute  yellow  atrophy  of  the 
liver;  hepatic  cirrhosis  or  congestion  ;  chronic 
malaria  ;  bronze  diabetes  ;  numerous  chronic 
skin  affections,  with  irregular  pigmentation  ; 
poisoning  with  various  drugs,  including  silver, 
arsenic,  and  picric  acid;  sarcoma;  alkaptonuria. 
Excessive  action  of  physic  ;  intestinal  catarrh; 
tumor  in  or  near  the  bowel  ;  poisonous  dose  of 
almost  any  metal  except  lead  ;  ruptured  pelvic 
abscess,  appendiceal  abscess  or  abscess  open- 
ing into  any  part  of  the  intestine  ;  appendici- 
tis ;  presence  of  ptomaines  or  toxins  ;  perni- 
cious anaemia  ;  cholera  ;  typhoid  fever  ;  Addi- 
son's disease  ;  syphilis  ;  influenza  ;  proctitis  ; 
pneumonia ;  tuberculosis  ;  ulceration  in  the 
bowel  from  any  cause  ;  the  exanthems  ;  fecal 
Stasis  from  prolonged  constipation  ;   uraemic 


l82 


METHODS    OF   EXAMINATION 


Depression, 
nervous. 


Emaciation, 


Eructations 


Excitability,  iindue. 


Flatulency, 
testinal. 


conditions  in  Bright's  disease  ;  achylia  gas- 
trica  ;  the  crisis  of  certain  fevers,  including  es- 
pecially febricula  and  simple  continued  fever  ; 
fright ;  anger  or  other  great  emotion  ;  neuras- 
thenia ;  exophthalmic  goiter  ;  movable  kidney  ; 
gastroptosis ;  any  of  the  forms  of  cholera  ;  re- 
troflectiou  of  the  uterus;  septicaemia;  diabetes  ; 
the  first  stage  of  dysentery;  intussusception; 
fissure  in  ano ;  excessive  ingestion  of  fruit  or 
certain  vegetables  or  any  other  food  causing 
excessive  fermentation  ;  hypochlorhydria  and 
exceptionally  hyperchlorhydria. 
mental  or  Achylia  gastrica  ;  hypochlorhydria;  excep- 
tionally hj'-perchlorhydria  ;  chronic  gastritis  ; 
chronic  enteritis  ;  diseases  of  the  sexual  or- 
gans, especially  ovarian  disease  ;  anaemia  or 
chlorosis  ;  obstruction  of  the  bile  duct  ;  chronic 
appendicitis  ;  underfeeding  ;  prolonged  loss  of 
sleep  ;  melancholia  ;  prolonged  overstrain  of 
brain  or  nervous  system  ;  neurasthenia  ;  any 
chronic  lowering  disease;  pregnancy. 
Tuberculosis  ;  Addison's  disease  ;  hysterical 
anorexia  ;  starvation  or  underfeeding  ;  chronic 
malarial  disease,  and  any  chronic  disease  pro- 
ducing a  profound  dycrasia;  cancer  or  sarcoma; 
chronic  inflammatory  diseases  of  the  intes- 
tines ;  chronic  diarrhea  ;  gastric  atrophy  ;  dil- 
atation of  the  stomach  ;  long-continued  fevers; 
prolonged  lactation  ;  marasmus  ;  stricture  of 
esophagus;  obstructed  pylorus;  obstruction  in- 
any  part  of  alimentary  canal;  very  prolonged 
gastric  ulcer  ;  chronic  suppuration  ;  intestinal 
parasites;  obstructed  thoracic  duct;  final  stages 
of  all  serious  diseases  ;  cholera  ;  diabetes. 
Acute  or  chronic  indigestion  ;  overfeeding : 
acute  or  chronic  gastritis  ;  fermentation  in  the 
stomach  or  small  intestines  ;  insufficiency  of 
cardia  ;  organic  affections  of  stomach  or  pan- 
creas ;  neurasthenia  or  h^'steria  ;  nervous  dys- 
pepsia ;  aneurism  of  thoracic  aorta ;  air  swal- 
lowing. 

Hyperchlorhydria;  neurasthenia; uratic  diathe- 
sis ;  pregnancy;  overstrain  of  the  nervous  sys- 
tem; prolonged  eye  strain  ;  cerebral  softening; 
alcoholism  or  excessive  use  of  nervine  drugs, 
gastric  or  in-  Chronic  indigestion;  nervous  dyspepsia;  neu- 
rasthenia or  nerve   exhaustion;  chronic  gas- 


A    SYMPTOMATIC    GUIDE    TO    DIAGNOSIS 


183 


Headache. 


Hemorrhage,  or  loss  of 
blood  or  altered  blood,  by 
the  mouth  or  rectum. 


tritis  or  enteritis  ;  chronic  appendicitis  ;  hys- 
teria ;  hyper-  or  hypochlorhydria  ;  carcinoma 
or  sarcoma  in  the  stomach  or  intestines;  intes- 
tinal obstruction  ;  peritoneal  adhesions. 
Constipation  and  various  diseases  of  the  digest- 
ive organs;  angemia  or  sudden  hemorrhage;  ne- 
phritis ;  constitutional  diseases  ;  specific  infec- 
tious diseases  and  the  onset  of  most  febrile  at- 
tacks; intoxications,  as  from  lead,  alcohol,  mer- 
cury, tobacco,  or  other  drugs  ;  high  blood  pres- 
sure; pregnancy  ;  uremia  ;  neuroses,  as  in  epi- 
lepsy, hysteria,  neurasthenia  ;  exophthalmic 
goiter  ;  overaction  of  amyl  nitrite  or  of  nitro- 
glycerin ;  blasting  or  other  work  with  dynamite; 
inflammatory  or  organic  diseases  involving  the 
nervous  system,  as  in  meningitis,  neuritis,  tu- 
mor, or  abscess  ;  reflex  from  diseases  of  the  ear, 
eye,  nasopharynx,  orsexual  organs;  physical  or 
mental  fatigue  ;  cerebral  congestion  or  soften- 
ing ;  cerebral  syphilis. 

Gastric  ulcer  or  erosions  ;  tubercular  phthisis  ; 
rupture  of  pulmonary  vessel  from  aneurism 
(hemoptysis);  hepatic  cirrhosis  ;  gastric  can- 
cer ;  aneurism  rupturing  into  esophagus,  stom- 
ach, or  intestines,  or  rupture  of  varicose  veins 
into  any  of  these  ;  enlarged  spleen  ;  injuries 
to  the  mouth,  nose,  or  throat  in  the  case  of 
unconscious  persons,  infants,  and  malingerers, 
the  blood  being  swallowed  ;  injury  to  stomach 
from  straining  or  blows  ;  vicarious  menstrua- 
tion by  way  of  the  stomach  ;  cancer  of  the 
liver  exceptionally ;  corrosive  poisons  swal- 
lowed;  severe  anaemias;  scurvy;  purpura 
haemorrhagica  ;  chronic  nephritis ;  certain 
acute  infectious  diseases,  such  as  yellow  fever, 
smallpox,  and  cholera  ;  acute  yellow  atrophy 
of  liver  ,  duodenal  ulcer  ;  typhoid,  dysenteric 
or  other  ulcers  of  the  intestines  ;  hemorrhoids; 
cancer  of  the  rectum  ;  foreign  bodies  ;  fissures 
or  polypi  of  rectum  ;  strangulated  hernia  ;  in- 
tussusception in  children  ;  colitis  in  children  ; 
amyloid  disease  of  the  intestines  ;  aneurism 
or  thrombosis  of  superior  mesenteric  artery  ; 
portal  thrombosis  ;  jaundice  ;  diarrheal  attacks 
complicating  exophthalmic  goiter  ;  intestinal 
parasites  ;  fecal  impaction  ;  unskilled  use  of 
instruments. 


1 84 


METHODS    OF   EXAMINATION 


Insomnia,     or 
sleep. 


Irritability  of  temper, 


Nausea,  or  vomiting 


impaired  Neurasthenia  ;  hyperchlorhydria  ;  gastric  or 
duodenal  ulcer  ;  constipation  ;  intestinal  ca- 
tarrh ;  cerebral  disease  ;  pain  anywhere  in  the 
body  from  cancer  or  other  cause  ;  deficient 
food  ;  overloaded  stomach  ;  indigestion,  gas- 
tric or  intestinal,  from  any  cause  ;  anxiety  or 
worry  ;  fear  or  any  powerful  emotion  ;  mental 
excitement  of  any  kind. 

Neurasthenia ;  chronic  indigestion  ;  loss  of 
sleep  ;  over-fatigue  of  nervous  system  ;  hyper- 
chlorhydria ;  the  uratic  diathesis  ;  impairment 
of  cerebral  tone  from  any  cause  ;  prolonged 
eye  strain  ;  pregnancy. 

Acute  or  subacute  gastritis  from  putrefying, 
indigestible,  or  irritating  food  ;  overloaded 
stomach  ;  chronic  gastritis  ;  alcoholism  ;  anaes- 
thetics or  opiates  in  full  doses  ;  spasmodic  or 
mechanical  obstruction  of  the  pylorus  from  a 
tumor  or  the  cicatrix  of  an  ulcer  causing  ste- 
nosis ;  gastric  cancer  ;  gastric  or  duodenal  ul- 
cer ;  dilatation  of  the  stomach  ;  irritant  poi- 
sons ;  administration  of  emetics  ;  pregnancy  ; 
locomotor  ataxia  ;  centric  or  toxaemic  as  seen 
in  Addison's  disease  ;  meningitis  ;  cerebral 
tumor,  abscess,  or  congestion  ;  acute  infectious 
diseases  and  onset  of  most  fevers  ;  reflex  of 
obscure  cerebral  origin  ;  irritation  of  pharynx, 
larynx,  or  thyroid  gland  ;  hardened  ear  wax  ; 
Bright's  disease  ;  appendicitis  ;  perforation  of 
the  intestines  ;  acute  peritonitis  ;  acute  enter- 
itis ;  incarcerated  or  strangulated  hernia  ;  in- 
testinal obstruction  from  any  one  of  numerous 
causes  ;  acute  disease  of  the  liver  ;  cholecys- 
titis, cancer,  or  other  disease  when  it  causes 
stenosis  of  the  bile  ducts  ;  hepatic  colic  ;  anae- 
mia ;  pyelitis  ;  movable  or  floating  kidney  ; 
ptosis  of  any  viscus ;  hydronephrosis  ;  disease 
of  the  pancreas ;  reflex  from  disease  of  the 
uterus,  ovaries,  or  tubes ;  reflex  from  diseased 
bladder  or  prostate  gland ;  hysteria ;  neuras- 
thenia; intestinal  parasites;  obstructed  ureter; 
subphrenic  abscess ;  stricture  of  the  esophagus ; 
migraine ;  prolonged  eye  strain  in  very  sus- 
ceptible persons;  any  one  of  various  renal 
affections,  as  calculus,  tuberculosis,  syphilis, 
cancer,  or  other  tumor  of  either  kidney. 


A    SYMPTOMATIC    GUIDE    TO    DIAGNOSIS 


185 


Oppression  or  weight   in 
stomach. 


Pain  referred  to  the  right 
hypochondriac  region  or 
lower  edge  of  liver. 


Pain,  referred  to  the  re- 
gion of  the  stomach. 


Pallor  of  the  skin. 


Chronic  gastritis;  nervous  dyspepsia  ;  neuras- 
thenia ;  premonitory  stage  of  gastric  hemor- 
rhage ;  atony  or  dilatation  of  the  stomach  ;  de- 
ficient secretion  of  HCl  and  the  ferments 
(hypopepsia  or  hypochlorhydria);  achylia  gas- 
trica ;  gastric  atrophy;  pyrosis;  gastric  hy- 
peracidity ;  any  form  of  acute  gastritis  ;  gastric 
ulcer  ;  gastric  cancer  ;  dilatation  of  the  stomach; 
diseases  of  the  pancreas  ;  chronic  gastritis. 
Hepatic  colic  ;  cholecystitis;  certain  diseases 
of  the  liver;  movable  right  kidney  ;  hydro- 
nephrosis ;  calculus  in  the  right  kidney  or  its 
pelvis  ;  renal  colic  ;  tumor  of  the  liver,  gall 
bladder,  bile  duct,  pylorus,  or  the  intestines  ; 
ulcer  of  the  pyloric  end  of  the  stomach  or  of 
duodenum  ;  rheumatism  ;  traumatism  ;  ulcer 
of  the  cecum  ;  right-sided  pleurisy  or  pneu- 
monia ;  diaphragmatic  pleurisy;  appendicitis. 
Excessive  secretion  of  HCl  (hyperchlorhydria); 
excessive  gastric  fermentation  with  large  form- 
ation of  organic  acids  and  gases  ;  round  ulcer 
or  erosions  of  the  stomach  ;  gastric  cancer  ; 
gastroptosis  ;  gastralgia  from  purely  nervous 
causes  ;  atony,  or  dilatation  of  the  stomach  ; 
foreign  bodies  swallowed  and  retained  in  the 
stomach  ;  ulcer  of  the  duodenum  ;  phlegmon- 
ous or  simple  acute  gastritis  ;  perigastritis  ; 
hyperaesthesia  of  the  gastric  mucous  mem- 
brane ;  acute  indigestion  ;  morphine  habit  ; 
disease  of  the  vertebrae  ;  pneumonia  in  chil- 
dren ;  cancer  or  inflammation  of  the  pancreas  ; 
disease  of  the  pleura ;  especially  diaphrag- 
matic pleurisy  ;  disease  of  the  heart  or  pericar- 
dium ;  affections  of  the  intercostal  nerves ; 
herpes  zoster  ;  kinking  of  the  ureter  in  cases 
of  movable  or  floating  kidney,  especially 
on  the  left  side  ;  abscess  of  the  liver ;  intes- 
tinal disorders;  cramp  of  the  gastric  muscles 
from  spasmodic  or  any  obstruction  of  the 
pylorus;  aneurism  of  the  abdominal  aorta; 
arteriosclerosis  of  the  abdominal  vessels ; 
rheumatism  of  the  abdominal  muscles  ;  pas- 
sage of  biliary  or  renal  calculi  ;  subphrenic 
abscess  ;  locomotor  ataxia  ;  hysteria  ;  hypo- 
chondriasis ;  localized  peritonitis  ;  traumatism. 
Recent  hemorrhage  ;  Bright's  disease  ;  tuber- 
culosis ;  malignant  growths  ;  acute  or  chronic 


1 86 


METHODS    OF   EXAMINATION 


Ptyalism,  or  salivation. 


Regurgitation,  or  rumina- 
tion. 


Succussion,  or   splashing 
sounds  in  the  abdomen. 


diarrhea  ;  chronic  gastric  or  intestinal  indiges- 
tion ;  chronic  gastric  ulcer  cr  severe  hemor- 
rhage in  an  acute  one;  chronic  gastric  catarrh  ; 
chronic  malaria  ;  syphilis  ;  gastric  dilatation  ; 
gastroptosis  or  enteroptesis  ;  morphine  habit 
and  some  other  drug  habits  ;  lead  poisoning  ; 
stricture  of  the  esophagus  ;  various  kinds  of - 
poisoning,  both  from  the  outside,  as  » from 
drugs,  illuminating  gas,  etc.,  or  from  auto- 
toxEemia  ;  prison  life  or  long  confinement  in 
any  badly  lighted  rooms  ;  starvation  ;  deficient 
oxygen  from  poor  ventilation  or  overcrowding, 
especially  in  cities  ;  chronic  ill  health  from 
almost  any  cause  ;  idiopathic  or  pernicious 
anasmia;  arteriosclerosis. 

Disease  of  the  teeth  or  gums;  dentition  ;  stom- 
atitis ;  glossitis  ;  mumps  ;  acute  tonsilitis  or 
peritonsilitis  (quinsy);  nausea  ;  disease  of  the 
pancreas  ;  any  one  of  various  diseases  of 
the  stomach  :  intestinal  worms  and  probably 
other  abnormal  conditions  in  the  bowels  ;  tu- 
mor of  the  medulla  or  facial  nerve  ;  pregnancy; 
facial  neuralgia  ;  mental  disease  ;  excessive 
mental  emotion  ;  pyschic  neurosis  ;  the  ac- 
tion of  certain  drugs,  especially  mercury  and 
gold  in  excessive  doses  or  small  doses  often  re- 
peated ;  strong  acids  or  alkalies  ;  jaborandi  ; 
physostigma;  muscarin;  tobacco;  the  prepara- 
tions and  compounds  of  iodine  and  copper  and 
the  nauseating  medicaments  ;  various  spicy 
food  accessories,  as  horseradish,  ginger,  etc.; 
some  obscure  diseases  of  the  brain  or  spinal 
cord,  as  some  forms  of  paralj'sis  ;  progressive 
muscular  atroph}^  ;  rabies  ;  hystero-epileps}^  ; 
atony  of  the  submaxillary  ganglion  ;  irritation 
of  cordi  tympani  ;  irritation  of  cervical  sympa- 
thetic ;  early  stages  of  variola  or  typhoid 
fever  ;  and  the  crises  of  fevers  exceptionally. 
Relaxation  of  cardiac  orifice  of  stomach  ;  neu- 
rosis; existence  of  sac  or  diverticulum  in  esoph- 
agus ;  habit ;  certain  forms  of  indigestion  ; 
insanity  ;  epilepsy  ;  idiocy  ;  neurasthenia  ; 
hj^steria. 

Aton3^  or  dilatation  of  stomach  ;  hydropneu- 
mopericardium  ;  gastroptosis  ;  enteroptosis  ; 
when  such  sounds  are  demonstrable  over  ce- 
cum,   sigmoid  flexure,    transverse     colon,    or 


A    SYMPTOMATIC    GUIDE    TO    DIAGNOSIS 


187 


Tenderness    on    pressure 
over  epigastrium. 


Tenesmus. 


Tongue  coated  or  furred. 


Tympany,  abdominal. 


Vertigo. 


other  part  of  the  large  intestine,  they  signify 
atony  or  dilatation  of  the  same. 
Functional  or  organic  disease  in  abdominal 
plexuses  of  the  sympathetic  nervous  system  ; 
gastric  or  duodenal  ulcer  ;  acute  or  chronic 
gastritis  ;  hypochondriasis  ;  hysteria  ;  Addi- 
son's disease  ;  gall  stones  ;  acute  yellow  atro- 
phy of  liver  ;  pancreatitis  ;  acute  pericarditis; 
diaphragmatic  pleurisy  ;  irritant  poisons  ;  peri- 
tonitis ;  aneurism  of  abdominal  aorta  ;  rheu- 
matism of  abdominal  muscles  ;  appendicitis 
exceptionally. 

Dysentery;,  proctitis;  catarrhal  enteritis; 
diarrhea  caused  by  irritant  poisons  ;  overac- 
tion  of  mercury  or  other  cathartics  ;  membran- 
ous enteritis  ;  irritable  bladder  with  vesical 
tenesmus  ;  impacted  faeces  ;  worms  ;  foreign 
body  in  rectum  ;  hemorrhoids  ;  polypus  ;  ade- 
noma or  cancer  of  rectum  ;  intussi>sception  in 
children  ;  enlarged  or  retroflexed  uterus. 
The  use  of  tobacco  ;  mouth-breathing  ;  naso- 
pharyngeal catarrh  ;  so-called  bilious  attacks  ; 
the  exanthems  or  any  fever  ;  any  systemic 
toxaemia  ;  autotox^mia  ;  gastritis  ;  gastro- 
duodenitis  ;  enteritis  ;  cancer  anywhere  in  ali- 
mentary canal ;  alcoholism  ;  milk  diet ;  neu- 
ralgia of  second  or  third  division  of  trigemi- 
nus ;  fracture  involving  foramen  rotundum 
(unilateral);  hemiplegia  ;  rough  tooth  ;  tonsil- 
itis  ;  thrush  ;  Riggs'  disease  ;  caries  of  the 
teeth  ;  disease  in  any  part  of  the  mouth  ; 
retropharyngeal  abscess. 

Gastric  or  intestinal  fermentation  ;  gastric  or 
intestinal  atony  ;  dilatation  of  the  stomach  ; 
gastric  catarrh,  cancer,  or  ulcer  ;  pyloric  ste- 
nosis ;  typhoid  fever  ;  appendicitis  ;  peritoni- 
tis ;  hysteria  (pneumatosis);  intestinal  obstruc- 
tion ;  sepsis  ;  strangulated  hernia  ;  pressure 
on  intestines  by  tumor  or  fluid  ;  defective  in- 
nervation with  either  atony  or  spastic  contrac- 
tion of  intestinal  walls  ;  constipation  ;  perforat- 
ing ulcer  of  stomach  or  intestines  ;  marked 
emphysema  ;  ascites  from  hepatic  cirrhosis  or 
other  causes  ;  acute  yellow  atrophy  of  liver  ; 
air  swallowing. 

Neurasthenia  ;  lith^mia;  gastric  hyperacidity; 
chronic  gastritis  ;  intestinal  parasites  ;  arteri- 


METHODS   OF   EXAMINATION 

osclerosis  ;  valvular  cardiac  disease  ;  injury  to 
vestibule  of  inner  ear  ;  aneurism  ;  Meniere's 
disease  ;  eye  strain  ;  epilepsy  ;  anaemia,  es- 
pecially on  exertion  ;  tumors  of  the  brain,  es- 
pecially of  the  cerebellum  ;  abuse  of  tea,  cof- 
fee, alcohol,  or  tobacco  ;  auto-intoxication  ; 
the  chronic  form  of  nephritis;  locomotor 
ataxia  ;  disseminated  sclerosis  (rarely);  men- 
tal strain  or  excitement  in  neurotic  persons  ; 
mechanical  disturbance  of  equilibrium  as  in 
seasickness,  in  railway  or  elevator  sickness  ; 
transitory,  as  in  looking  at  a  rapidly  rotating 
body  ;•  vertical,  caused  by  looking  down  from 
a  height  ;  lateral,  which  may  occur  in  a  person 
walking  alongside  a  fence  ;  nocturnal,  felt  in 
act  of  going  to  sleep. 


PART   III 
METHODS  OF    TREATMENT 


LECTURE  XVI 

PROPHYLAXIS:    PERSONAL  HYGIENE  AND 
FOOD    REQUIREMENTS 

Prophylaxis^  if  not  exactly  treatment,  is  better  than  treat- 
ment. To  prevent  disease  is  always  much  better  even  than  to 
cure  it  when  it  has  come.  This  is  true  from  the  humanitarian 
point  of  view  if  not  according  to  business  principles;  and  in 
these  lectures  I  shall  teach  you  that  medicine  is  something 
more  than  business  or  a  trade — that  it  is  our  duty  as  physicians 
endowed  with  superior  knowledge  upon  such  subjects,  not  only 
to  protect  in  all  possible  ways  from  the  dangers  of  disease 
the  families  and  individuals  intrusted  to  our  care,  but  also  to 
aid  in  protecting  the  communities  wherein  we  dwell,  by  giving 
timely  warning  as  to  threatening  unhygienic  conditions  and 
pointing  out  the  way  to  remedy  them. 

Professor  R.  A.  F.  Penrose,  in  lecturing  upon  obstetrics 
some  thirty-five  years  ago,  was  accustomed  to  say  that  the 
best  way  to  insure  the  birth  of  healthy  children  was  to  see  to 
it  that  the  building  material  was  good — /.  c,  to  make  sure  that 
the  ancestors  were  healthy.  The  same  may  be  said  as  to  pre- 
venting disease  of  the  digestive  system ;  the  surest  way  to 
secure  healthy  digestive  organs  is  to  be  born  with  them. 

Unfortunately,  however,  a  very  large  proportion  of  civilized 
mankind  are  born  with  a  strong  predisposition  to  disease  of 
these  organs,  and  such  persons  need  to  be  doubly  careful  to 
follow  hygienic  rules.  By  living  temperately,  eating  the 
foods  best  adapted  for  easy  and  rapid  digestion,  masticating 
all  ingesta  with  the  greatest  possible  thoroughness,  and  avoid- 
ing all  excesses  and  irregularities,  not  only  in  eating  and 
drinking,  but  also  in  work  and  play,  such  inheritors  of  poor 
constitutions,    including    especially    faulty    digestive    systems, 

191 


192  METHODS    OF    TREATMENT 

may  often,  and  constantly  do,  greatly  ontlive  the  most  robust 
people  whose  lives  are  full  of  dissipation  and  reckless  disre- 
gard of  hygiene.  This  subject  of  prophylaxis  will  come  up 
particularly  in  advising  as  to  the  care  of  children,  their  diet, 
exercise,  baths,  physical  training,  education,  and,  later,  the 
choice  of  an  occupation.  As  to  all  of  these,  you,  as  family 
physicians,  will  be,  or  should  be,  called  upon  to  decide  and  lay 
down  for  the  parents  explicit  directions  regarding  every  detail. 
To  consider  all  these  subjects  as  fully  as  their  importance 
demands  is  impracticable  in  this  place,  and  you  will  find  them 
exhaustivel}^  discussed  in  the  best  works  on  pediatrics.  A  few 
g'eneral  principles,  however,  should  govern  in  the  hygienic 
management  not  only  of  delicate  children,  but  of  adults  who 
have  a  predisposition  to  digestive  disorders.  These  may  be 
summarized  briefly  as  follows :  Secure  for  them,  first  of  all, 
an  abundance  of  pure  fresh  air  both  by  day  and  by  night. 
When  practicable,  such  children  or  older  patients  should  live 
in  the  country  with  plenty  of  open  spaces  about  their  houses, 
and  the  latter  should  be  equipped  with  perfect  systems  of 
ventilation. 

Personal  Hygiene. — In  reality,  everything  pertaining  to 
both  personal  and  public  health  is  in  direct  relation  to  the  pre- 
vention of  gastro-intestinal  diseases,  since  all  h3^gienic  faults 
tend  to  lower  the  nerve  tone  and  set  up  finally  disease  in  vari- 
ous parts  of  the  body,  including  nearly  always  the  digestive 
system.  The  different  systems  are  in  such  close  sympathetic 
relation  with  each  other  that  no  one  of  them  can  be  seriously 
injured  without  the  others  being  liable  and  likely  to  become 
ultimately  involved. 

Besides  care  of  the  diet,  the  hygienic  precautions  which  are 
especially  important  to  prevent  the  development  of  disease  in 
the  alimentary  canal  should  include  an  abundance  of  pure, 
fresh  air  (good  ventilation),  a  proper  .development  of  the 
muscles,  especially  the  trunk  muscles  (secured  by  outdoor  ex- 
ercise in  part),  and  the  daily  use  of  them  in  such  a  way  as  to 
stimulate  gastric  and  intestinal  peristalsis  and  insure  a  suffi- 


prophylaxis:  personal  hygiene  193 

ciently  active  circulation  of  the  blood  in  all  of  the  digestive 
glands.  This  is  constantly  neglected  by  most  professional 
persons  and  sedentary  workers,  to  say  nothing  of  the  idle  class. 

Delicate  persons  need  also  to  take  specially  good  care  of  the 
skin,  by  which  is  meant  not  only  keeping  the  latter  clean,  since 
warm  baths  for  this  purpose  are  often  greatly  abused,  but  also 
a  proper  training  of  it  by  a  daily  rubbing  or  kneading  of  the 
entire  surface  of  the  body,  which  can  be  most  efficiently  done 
in  most  cases  after  a  transient  application  of  cold  water  with 
a  sponge  or  wet  towel. 

Such  a  daily  practice  is  of  the  greatest  efficacy  in  maintain- 
ing an  active  circulation  of  the  blood  in  the  skin,  by  means  of 
which  liability  to  take  cold  upon  ordinary  exposure  to  changes 
of  temperature,  and  the  danger  of  internal  congestions,  is 
greatly  lessened.  The  prophylactic  value  of  these  two  prac- 
tices— daily  exercise  of  the  trunk  muscles  and  surface  fric- 
tions, especially  after  the  application  of  cold  water— ;-can 
scarcely  be  overestimated. 

The  teeth  and  gums  should  also  receive  special  care.  At 
least  once  daily  the  teeth  should  be  brushed  in  such  a  way  as 
to  remove  all  remaining  particles  of  food,  and  it  is  safest  to 
cleanse  the  teeth  after  every  meal. 

When  such  pains  are  taken  to  keep  the  teeth  and  gums 
always  free  from  decomposing  matter,  there  is  infinitely  less 
liability  to  the  development  of  caries  or  other  disease  in  or 
about  the  teeth  ;  but,  in  addition  to  these  precautions,  every  per- 
son should  have  his  mouth  examined  by  a  dentist  once  or 
twice  a  year  to  see  that  no  disease  has  been  set  up  in  any  of 
its  structures  that  could  carry  infection  into  the  parts  below. 
There  cannot  be  good  digestion  without  efficient  mastication, 
and  this  is  impossible  without  good  teeth. 

Care  should  be  taken  also  to  avoid  the  development  of 
chronic  catarrhal  disease  in  the  nose,  nasopharynx,  or 
pharynx,  since  the  mucus  swallowed  from  these  parts  is  always 
swarming  with  bacteria,  and  liable  finally  to  infect  the 
stomach. 


194  METHODS    OF    TREATMENT 

People  who  inherit  a  tendency  to  indigestion  should  go  to 
the  table  with  a  quiet  mind  and  avoid  eating  while  seriously- 
fatigued.  They  should  spend  plenty  of  time  at  meals,  and  en- 
gage in  no  active  work,  either  mental  or  physical,  for  half  an 
hour  after  their  lighter  meals,  or  for  a  full  hour  at  least  after 
dinner.  When  the  digestion  is  already  much  impaired  the  re- 
cumbent posture  for  some  time  after  each  meal  will  be  advan- 
tageous. Such  persons  should  lead  as  quiet,  even  lives  as  pos- 
sible, avoiding  all  excesses,  every  form  of  overstrain,  mental, 
physical  or  emotional,  especially  sexual  excesses  or  ir- 
regularities. 

Seven  to  eight  hours  daily  of  sound,  refreshing  sleep  are  also 
requisite  to  good  health;  but  if  the  foregoing  health  rules  are 
strictly  followed,  good  sleep  will  naturally  follow,  except  in 
conditions  of  disease,  when  the  cause  needs  to  be  removed  by 
having  the  disturbing  disease  cured.  Hypnotic  drugs  rarely 
effect  the  end  desired.  They  always  do  harm  when  long  con- 
tinued, and  fail  frequently  to  afford  even  temporary  relief. 
The  taking  of  them  should  never  be  left  to  the  discretion  of  the 
patient. 

As  to  clothing,  the  indications  should  be  plain :  Allow  as  lit- 
tle constriction  of  the  body,  especially  about  the  chest  and  upper 
abdomen,  as  possible;  and  for  those  who  are  most  of  the  time 
indoors  the  rule  should  be  to  wear  no  heavier  clothes  than  are 
necessary  to  keep  them  comfortable  in  warm  rooms,  extra 
wraps  to  be  put  on  when  necessary  for  any  unusual  exposure. 

The  Hygiene  of  Eating  and  Drinking. — The  food  should  be 
simple,  digestible,  and  thoroughly  prepared  for  ingestion  in 
the  case  of  older  children  and  adults  by  sufficient  mastication 
and  insalivation.  The  meals  should  be  neither  too  near  to- 
gether nor  too  far  apart.  For  invalids  numerous  small  feed- 
ings are  sometimes  best,  but  in  the  case  of  adults  not  ill  more 
than  three  or  four  meals  a  day  are  inadvisable,  and  there 
should  rarely  be  less  than  two.  It  is  important,  of  course,  that 
delicate  persons  should  not  fail  to  take  enough  nourishment  to 
maintain  nutrition  certainly  at  the  proper  level,  and  more  care 


prophylaxis:  personal  hygiene  195 

is  necessary  in  this  respect  for  them  than  for  other  persons. 
On  the  other  hand,  it  is  equahy  important  to  avoid  overeating, 
and  this  danger,  for  most  Americans  at  least,  is  greater  than 
the  other.  There  should  be  always  the  proper  ratio  between 
alimentation  and  oxygenation,  as  I  have  pointed  out  hitherto 
in  various  papers  concerning  the  management  of  consumptives 
and  other  classes  of  invalids.^  In  other  words,  the  more  oxy- 
gen one  takes  into  one's  lungs  the  more  food  one  requires  and 
can  safely  take,  whether  the  oxygen  be  secured  by  abundant 
ventilation  while  resting  indoors,  by  spending  much  time  in 
the  open  air,  even  sitting  on  piazzas,  or  better,  by  enjoying 
such  passive  outdoor  exercise  as  driving,  automobiling,  or  sail- 
ing, by  active  exercise  indoors  with  good  ventilation,  or  best 
of  all  by  active  exercise  in  the  open  air. 

Definition  of  Food. — It  will  be  in  place  here  to  define  what 
food  is,  and  I  have  tried  to  formulate  in  few  words  a  satisfac- 
tory definition  of  it.  A  food  is  any  substance  which,  when 
introduced  into  the  system,  can  supply  heat  or  force  or  repair 
tissue  waste  zvithout  exerting  any  disturbing  or  medicinal 
action. 

Alcohol  and  Food  Accessories. — You  will  observe  that  by 
no  possible  twisting  of  this  definition  can  it  be  made  to  include 
alcohol  or  any  of  the  so-called  food  accessories  which  are  often 
taken  with  our  food  for  the  purpose  of  stimulating  either  the 
brain  or  other  part  of  the  nervous  system,  or  the  digestive 
apparatus. 

In  making  a  clear  and  sharp  distinction  between  the  foods 
proper  and  the  numerous  substances  which,  by  a  confusion  of 
thought,  are  often  represented  as  in  some  sense  foods,  I  by  no 
means  intend  to  condemn  in  toto  the  use  of  the  latter  sub- 
stances. I  only  insist  upon  clear  definitions  of  them  and  clean- 
cut  conceptions  concerning  them.  I  believe  that  the  savory 
spices  are  sometimes  useful  in  disease,  and  in  their  moderate  use 
by  adults  often  excusable  in  health  for  the  reason  that  tempo- 

1  The  Ratio  that  Alimentation  should  Bear  to  Oxygenation  in  Disease 
of  the  Lungs,  T/ie  Med.  News,  September  22,  1894. 


196  METHODS    OF    TREATMENT 

rarily  they  may  perform  a  needed  service  by  increasing  the 
appetite  and  the  enjoyment  of  dining.  But  for  their  injurious 
after-effects  the  same  might  be  said  of  alcohohc  beverages. 
They  increase  the  sociabihty  of  festive  occasions.  It  seems  to 
me  in  the  highest  degree  important  that  in  the  instruction  of 
the  young  the  exact  scientific  truth  should  be  taught,  and  that 
in  the  management  of  dehcate  invaHds,  with  irritable  nervous 
systems  and  greatly  enfeebled  digestions,  we  physicians  should 
not  deceive  ourselves  and  our  patients  by  a  confusion  of  defini- 
tions and  reasoning  regarding  such  substances.  Let  us  call  a 
spade  a  spade,  and  limit  the  word  food  to  substances  useful 
for  nutrition,  and  class  strictly  as  medicines  or  drugs  all  those 
articles  which,  being  entirely  without  true  food  value,  find 
their  chief  use  as  stimulants  or  irritants  of  tissue.  The  fact 
that  alcohol  can  be  consumed  in  the  body  to  some  extent  with 
the  production  of  heat,  no  more  makes  it  a  food  than  the  fact 
that  both  it  and  benzine  can  be  burned  in  stoves  with  the  lib- 
eration of  heat,  constitutes  these  substances  fuels.  In  both 
cases  the  process  of  combustion  is  more  or  less  unmanageable 
and  liable  to  be  followed  by  dangerous  results. 

In  health,  exercise  and  sufficient  fresh  air  with  the  fesultant 
oxidation  processes  are  the  normal  excitants  of  appetite.  When 
we  eat  our  meals  in  good  company  and  amid  as  pleasant  sur- 
roundings as  possible,  after  a  sufficient  lapse  of  time  since  the 
previous  meal,  we  do  not,  unless  out  of  health,  need  any  arti- 
ficial irritant  to  produce  a  flow  either  of  saliva,  of  gastric  juice, 
of  bile,  or  any  other  of  the  digestive  juices.  Prolonged  mas- 
tication will  insure  abundant  insalivation  at  least. 

If  we  are  out  of  health  we  need  a  physician,  and  sometimes, 
doubtless,  medicine,  to  overcome  a  persistently  deficient  secre- 
tion ;  but  physicians  do  not  usually  find  it  advantageous  to 
recommend  the  constant  use  of  any  one  drug  year  after  year, 
and  so  on  through  life.  Indeed,  competent  observers  agree 
that  the  prolonged  use  of  any  drug  which  at  first  produces 
stimulation  will,  in  the  end,  cause  overstimulation  and,  finally, 
depression  of  the  parts  stimulated. 


prophylaxis:  personal  hygiene  197 

When,  therefore,  we  reg'ularly  and  habitually  take  with  our 
meals  alcoholic  beverages,  tea,  or  coffee,  or  any  of  the  spices 
beyond  the  very  small  amount  required  to  give  a  slight  flavor 
to  the  food,  we  should  do  so  solely  on  the  ground  that  we  like 
them  and  enjoy  the  taste  of  them  as  well  as  the  stimulating 
effect  of  them  upon  the  nervous  system.  With  this  clear 
understanding  of  the  matter,  we  shall  be  less  likely  to  abuse 
these  substances,  and  to  force  them  upon  the  unwilling  palates 
of  children  at  an  age  when  they  can  do  most  harm,  and  when 
there  can  scarcely  exist  even  the  possibility  of  benefit  to  be 
derived  from  them. 

Having  thus  disposed  of  food  accessories  which  are  not 
foods  at  all,  we  come  now  to  the 

Classification  of  Foods, — The  usual  division  is  into  pro- 
teids,  carbohydrates,  hydrocarbons  or  fats,  salts,  and  water. 

The  proteids  are  nitrog-enous  elements  obtained  usually 
from  the  flesh  of  animals,  from  eggs,  milk,  the  legumes 
(beans,  peas,  etc.),  the  grains,  and  other  vegetable  sources. 
They  are  indispensable  for  the  repair  of  tissue  waste,  since 
they  enter  into  the  -composition  of  the  cells  of  all  the  structures 
of  the -body.  They  are  also  to  some  extent  utilized  for  the 
production  of  heat  and  force. 

The  carbohydrates,  as  the  name  indicates,  are  foods  contain- 
ing carbon  and  hydrogen,  along  with  generally  other  elements, 
but  usually  no  nitrogen,  and  are  obtained  from  a  great  variety 
of  sources,  including  especially  the  grains,  the  legumes,  and 
other  vegetables,  fruits,  etc.  They  are  practically  non-existent 
in  meats  and  fish.  The  carbohydrates  are  oxidized  in  the 
body  with  the  production  of  heat  and  force. 

Fats,  or  the  oily  part  of  food,  are  obtained  from  both  the 
animal  and  vegetable  kingdoms,  and  like  the  carbohydrates, 
find  their  use  in  producing  force  and  maintaining  the  heat  of 
the  body.  For  these  purposes  they  are  more  efficient  than  the 
former,  though  for  many  persons  they  are  decidedly  less 
digestible. 

The  salts  include  the  chloride  of  sodium,  carbonate  of  so- 


198 


METHODS    OF    TREATMENT 


dium,  and  phosphates  and  sulphates  of  potassium,  sodium,  and 
magnesium  as  well  as  minute  amounts  of  iron  and  of  certain 
other  metals. 

Water  constitutes  a  very  large  proportion  of  the  body,  being 
about  two-thirds  the  amount  of  the  whole  by  weight.  It  is  the 
most  universal  solvent  in  Nature,  and  plays  a  most  important 
role  in  the  processes  of  nutrition.  All  of  these  food  elements 
are  necessary  to  perfect  health,  though  one  or  more  of  them  can 
be  dispensed  with  for  short  periods.  Since  the  proteids  are  in- 
dispensable for  the  repair  of  tissue  waste  and  are  also  available 
to  some  extent  for  the  production  of  heat  and  force,  life  can 
be  maintained  longer  upon  a  proteid  diet  with  the  addition  of 
sufficient  water  and  salines  than  would  be  possible  with  a  diet 
embracing  all  other  varieties  of  food,  but  without  proteids. 
When  a  person  attempts  to  live  for  prolonged  periods  upon  a 
diet  containing  but  little  proteid  material,  the  necessary  nitro- 
gen is  taken  from  the  muscular  and  other  tissues  of  the  body 
itself  and  in  this  way  a  serious  form  of  wasting  occurs.  Ex- 
amples of  the  kind  have  been  noted  in  poor  sewing  women  of 
cities  who  have  endeavored  to  live  upon  a  diet  of  white  bread 
and  butter  and  tea,  with  the  inevitable  result  of  a  serious  loss 
of  flesh  and  strength.  Various  estimates  have  been  given  by 
authors  of  the  relative  proportions  of  proteids,  carbohydrates, 
etc.,  required  to  maintain  nutrition.  The  following  table  gives 
the  estimates  of  five  prominent  physiologists  as  to  the  food 
requirements  of  healthy  men  engaged  in  moderate  manual 
labor : 

PROPORTIONS  OF  DIFFERENT  FOODS  IN  THE  NORMAL  DIET 
ACCORDING  TO  VARIOUS  AUTHORITIES 


MOLESCHOTT 

Ranke 

VOIT 

Foster 

Atwater 

Grms. 

Grms. 

Grms. 

Grms. 

Grms. 

Proteid      . 

130 

100 

118 

131 

125 

Fats    or    Hydrocar- 

bons 

40 

100 

56 

68 

125 

Carbohydrates . 

550 

240 

500 

494 

400 

PROPHYLAXIS  :    PERSONAL    HYGIENE 


199 


You  should  bear  in  mind  that  women  require,  on  an  average, 
less  than  men,  and  that  a  person  at  rest  can  be  adequately  sus- 
tained, without  loss  of  weight,  on  somewhat  more  than  one- 
half  the  quantities  of  food  required  for  one  employed  at 
manual  labor. 

FOOD  REQUIREMENTS  UNDER  DIFFERENT  CONDITIONS 

The  following  table  of   standards   for  American   dietaries  is  given   by 

Atwater 


Woman  with  light  muscular  exercise 
Woman  with  moderate  muscular  work 
Man  without  muscular  work 
Man  with  light  muscular  work 
Man  with  moderate  muscular  work 
Man  with  hard  muscular  work 


1    Proteid 

Fuel  value 

Grams 

Calories 

90 

2,400 

100 

2,700 

112 

3,000 

125 

3,000 

150 

4-500 

Nutritive 
ratio 


1:5-5 
1:5-6 

1:5.5 

1:5-8 
1:6.3 


That  even  the  lowest  of  the  figures  given  in  the  foregoing 
tables  are  excessively  high  has  long  been  maintained  by  some 
writers,  and  especially  that  the  amounts  of  proteid  therein 
prescribed  are  excessive  for  the  real  needs  of  nutrition. 

Some  Recent  Experiments  Concerning  Food  Requirements. 
— Professor  R.  H.  Chittenden,  Director  of  the  Sheffield  Scien- 
tific School  of  Yale  University,  in  a  recent  very  interesting  and 
suggestive  article  on  this  subject,  entitled  "  Physiological 
Economy  in  Nutrition,"^  wrote:  "Why,  now,  should  we 
assume  that  a  daily  diet  of  over  100  grams  of  proteids,  with 
fats  and  carbohydrates  sufficient  to  make  up  a  fuel  value  of 
over  3000  large  calories,  is  a  necessary  recjuisite  of  bodily 
vigor  and  physical  and  mental  fitness?  Mainly  because  of  the 
supposition  that  true  dietary  standards  may  be  learned  by  ob- 


Popular  Science  Monthly,  June,  1903. 


200  METHODS    OF    TREATMENT 

serving  the  relative  amounts  of  nutrients  actually  consumed 
by  a  large  number  of  individuals  so  situated  that  the  choice 
of  food  is  unrestricted.  But  this  does  not  constitute  very 
sounct  evidence.  It  certainly  is  not  above  criticism.  We  may 
well  ask  ourselves  whether  man  has  yet  learned  wisdom  with 
regard  to  himself,  and  whether  his  instincts  and  appetites  are 
to  be  entirely  trusted  as  safe  guides  to  follow  in  the  matter  of 
his  own  nutrition.  The  experiments  of  Kumagawa,  Siven, 
and  other  physiologists  have  certainly  shown  that  men  may 
live  and  thrive,  for  a  time  at  least,  on  amounts  of  proteid  per 
day  equal  to  only  one-half  the  amount  called  for  in  the  Voit 
standard.  Siven's  experiments,  in  particular,  certainly  indi- 
cate that  the  human  organism  can  maintain  itself  in  nitrog- 
enous equilibrium  with  far  smaller  amounts  of  proteid  in  the 
diet  than  is  ordinarily  taught,  and  further,  that  this  can  be 
attained  without  unduly  increasing  the  total  calories  of  the 
food  intake." 

In  the  same  article  from  which  the  above  is  taken.  Professor 
Chittenden  describes  some  carefully  conducted  experiments 
upon  a  gentleman  (Horace  Fletcher)  whom  he  refers  to  as 
having  "  for  some  five  years  in  pursuit  of  a  study  of  the  subject 
of  human  nutrition,  practiced  a  certain  degree  of  abstinence 
in  the  taking  of  food  and  attained  important  economy  with, 
as  he  believes,  great  gain  in  bodily  and  mental  vigor,  and  with 
marked  improvement  in  his  general  health."  Omitting  com- 
ments and  details  for  which  there  is  not  room  here,  I  will 
again  cjuote  Professor  Chittenden's  own  words  as  to  the  re- 
sults of  these  experiments : 

"  For  a  period  of  thirteen  days,  in  January,  he  was  under 
observation  in  the  writer's  laboratory,  his  excretions  being 
analyzed  daily  with  a  view  to  ascertaining  the  exact  amount 
of  proteid  consumed.  The  results  showed  that  the  average 
daily  amount  was  41.25  grams,  the  body  weight  (165  pounds) 
remaining  practically  constant." 

This  amount  of  proteid,  which  sufficed  for  the  needs  of 
nutrition,  was  only  a  little  more  than  one-third  of  that  laid 


PROPHYLAXIS  :    PERSONAL    HYGIENE  20I 

down  by  Voit  as  the  standard  requirement,  or  to  be  exact,  34.9 
per  cent,  of  Voit's  figures. 

In  a  subsequent  experiment  the  subject,  Mr.  Fletcher,  was 
required  to  perform  daily  in  the  Yale  University  Gymnasium 
the  same  exercises  given  to  the  'Varsity  Crew,  which,  as 
described  by  the  director  of  the  gymnasium  who  supervised 
this  part  of  the  experiment,  "  are  drastic  and  fatiguing  and 
cannot  be  done  by  beginners  without  soreness  and  pain  result- 
ing."    Yet  he  was  not  in  the  least  disturbed  by  them. 

The  noteworthy  points  in  the  results  of  the  second  experi- 
ments as  described  by  Professor  Chittenden  are  that,  though 
the  subject  of  the  experiment  fully  satisfied  his  appetite,  not 
having  been  under  any  restrictions  as  to  either  quality  or 
quantity  of  the  food,  and  performed  a  large  amount  of  violent 
exercise  daily  during  the  entire  experiment,  his  consumption 
of  proteid  averaged  less  than  45  grams  daily  as  compared 
with  the  118  grams  prescribed  by  Voit,  125  by  Atwater,  and 
130  by  Moleschott  for  the  average  proteid  ration  of  a  man  at 
moderate  labor,  while  his  total  intake  of  food  amounted  to 
only  1606  calories  or  heat  units  as  against  the  3000  to  4500 
considered  necessary  in  such  a  case  by  the  same  physiologists. 
Moreover  there  was  no  loss  of  weight  during  the  experiment. 
Apparently  nutrition  was  completely  sustained  in  every 
respect. 

The  subject  of  the  experiments  above  referred  to,  Mr. 
Horace  Fletcher,  is  the  author  of  several  books  on  topics  con- 
nected with  eating,  nutrition,  etc.  His  particular  hobby  is 
what  he  calls  "  overmastication,"  that  is,  masticating  or  in- 
salivating in  some  way  all  food  whether  solid,  pultaceous,  or 
Hquid,  very  much  more  completely  than  is  usual  with  even  the 
most  careful  of  eaters.  He  claims  that  by  this  means  one  may 
not  only  maintain  nutrition  on  greatly  less  than  the  usual  food 
ration,  but  acquire  a  pharyngeal  or  buccal  reflex  which  will 
unerringly  indicate  both  when  each  bolus  has  been  properly 
prepared  for  swallowing  and  when  enough  has  been  eaten  at 
any  meal  for  the  needs  of  the  body.     Indeed,  he  maintains 


202  METHODS    OF    TREATMENT 

that  after  practicing  this  method  for  a  month  or  six  weeks,  it 
will  be  difficult  for  one  to  swallow  any  morsel  of  food  until 
it  has  been  sufficiently  masticated  and  insalivated. 

Ifi  this  fast-eating  age  the  need  of  more  thorough  mastica- 
tion and  insalivation  is  a  most  important  theme  upon  which  to 
preach  a  new  gospel  and  Mr.  Fletcher  cannot  dwell  upon  it 
too  long  or  too  earnestly.  However,  the  results  of  experi- 
ments with  him  as  a  subject  will  not  hold  good  for  others  unless 
they  patiently  learn  and  practice  his  method  of  eating  and 
chewing,  and  it  will  require  a  lot  of  missionary  work  to  induce 
the  rest  of  mankind  to  follow  his  example.  Until  then  most 
people  will  go  on  eating,  or  bolting,  twice  the  amount  they  need, 
washing  much  of  it  down  with  liquids  instead  of  preparing  it 
as  Nature  intended,  and  then  calling  upon  physicians  to  repair 
the  damages  that  must  inevitably  result. 

Moreover,  experience  teaches  that  we  must  sometimes  tem- 
porarily allow  patients  with  certain  gastric  or  intestinal  af- 
fections, especially  catarrhal  affections,  a  disproportionately 
large  amount  of  some  animal  proteid — in  the  form  preferably 
of  meat  pulp,  meat  juice  (fresh),  meat  powder,  or  finely  hashed 
beef — because  it  stimulates  the  gastric  juice  and  the  depressed 
nervous  system  more  and  is  very  much  less  liable  to  fermenta- 
tion than  the  carbohydrates. 

As  a  measure  of  prophylaxis  it  will  be  advisable,  however, 
in  all  cases  except  in  those  forms  of  disease  requiring  a  spe- 
cial modification  of  the  diet,  to  keep  rather  closely  to  the  rela- 
tive proportions  of  the  several  classes  of  foods  given  in  the 
foregoing  tables,  except  that  recent  observations  have  proved 
that  the  proteid  element  should  be  much  less  than  formerly  ad- 
vised. It  is  not  well  to  advise  for  prolonged  use  any  form  of  a 
one-sided  diet,  such  as  one  consisting  largely  of  meat  or  of 
milk  or  even  exclusively  of  vegetables.  The  vegetable  king- 
dom, including  the  legumes,  can  indeed  supply  all  the  food  ele- 
ments required,  since  dried  beans  and  peas  contain  an  even 
larger  percentage  of  proteid  material  than  meat. 

For  persons  with  a  normal  digestion  a  strict  vegetable  diet 


PROPHYLAXIS  :    PERSONAL    HYGIENE  203 

may  be  made  to  meet  all  the  needs  of  nutrition,  and  there  is 
much  evidence  to  show  that  such  persons  often  win  in  contests 
of  physical  endurance  against  flesh-eating  competitors.  Some 
of  the  peoples  who  subsist  upon  vegetables,  fruit  and  nuts, 
with  rarely  any  flesh  food  except  occasionally  a  little  fish,  are 
noted  for  the  muscular  strength  of  their  working  class  espe- 
cially ;  but  no  such  peoples  have  ever  been  distinguished  for  in- 
tellectual attainments  or  excelled  in  the  mental  vigor  and 
organizing  ability  which  have  helped  some  of  the  meat-eating 
nations  to  extend  their  sway  over  a  large  part  of  the  world,  un- 
less we  except  the  Japanese,  and  it  is  noteworthy  that  their  re- 
markably rapid  developmerii',  both  mental  and  physical,  has 
been  contemporaneous  with  an  increased  use  of  flesh  foods  by 
all  of  them  except  the  poorest  class. 

This  question  as  to  the  best  diet  in  health  and  disease  has  not 
yet  been  finally  settled,  and  conservative  thinkers  are  not  pre- 
pared to  accept  the  conclusions  of  the  extremists  on  either  side. 
Certain  it  is,  however,  that  the  coarser  cereals,  acid  fruits,  raw 
nuts,  and  especially  uncooked  starch,  prove  harmful  to  most 
persons  who  have  diseased  stomachs  or  intestines. 

It  will  be  well  if  you  can  succeed  in  inducing  your  patients 
to  keep  down  the  proportion  of  flesh  foods  at  least  to  that 
amount  which,  added  to  the  proteids  in  the  bread,  cereals,  and 
vegetables  eaten,  will  make  up  the  one-fifth  part  of  their  total 
diet  held  by  Voit  and  others  to  be  the  normal  requirement  of 
this  form  of  aliment.  Even  that  will  probably  be  much  more 
than  they  really  need.  The  majority  of  Americans  of  the 
leisure  class,  and  many  of  the  humbler  class,  eat  excessively  of 
meat  in  addition  to  large  cjuantities  of  the  rich  proteid-bearing 
cereals  and  legumes,  thus  greatly  exceeding  the  above-stated 
proteid  requirements,  with  the  result  of  overtaxed  livers  and 
kidneys  as  well  as  sclerotic  arteries  often  before  middle  life. 


LECTURE  XVII 

GENERAL    CONSIDERATIONS     CONCERN- 
ING   DIET    AND    DIETOTHERAPY 

Sufficient  is  now  known  to  prove  beyond  question  that  by 
means  of  appropriate  diet,  in  connection  with  rest  and  exer- 
cise, much  more  can  be  accomphihed  in  many  diseases  of  the 
digestive  organs  than  is  possible  of  accomphshment  through 
the  use  of  drugs  or  any  other  form  of  therapy  alone.  We 
know,  for  example,  that  certain  gas^ic  affections  are  a  direct 
or  indirect  result  of  eating  too  much  or  too  fast  with  insuffi- 
cient mastication  of  foods  which  are  not  themselves  very  in- 
digestible, or  of  eating  when,  on  account  of  intense  mental  con- 
centration, recent  violent  exercise,  or  a  greatly  exhausted  con- 
dition of  the  nervous  system,  an  insufficient  amount  of  blood 
can  reach  the  digestive  glands.  A  similar  statement  is  ap- 
plicable to  a  number  of  intestinal  troubles. 

RELATIVE    IMPORTANCE    OF   DIETETICS  — RESTING    THE 

STOMACH 

Wegele's  Estimate  of  Dietetics — A  prominent  German 
author  some  ye'ars  ago  wrote  a  work  on  diseases  of  the 
stomach  and  bowels,  dividing  it  into  two  volumes.^  The  first 
volume  was  devoted  entirely  to  the  dietetic  treatment  of  such 
affections  and  included  an  appendix  made  up  of  culinary 
recipes.  Of  the  second  volume  the  first  part,  embracing  nearly 
one-half  of  the  book,  was  occupied  with  a  consideration  of  the 
physical  or  mechanical  methods  of  treatment  such  as  lavage, 

i"Die  diaetetische  Behandlung  d.  Magen-Darmerkrankungen,'"  and 
"Die  physikalische  und  medicamentoese  Behandlung  d.  Magen-Darm- 
erkrankungen," von  Dr.  Carl  Wegele,  Jena,  1893  and  1895. 

204 


CONSIDERATIONS    CONCERNING    DIET  205 

irrigation  of  the  bowels,  nutrient  enemas,  massage,  electrical 
applications  to  the  stomach  and  intestines,  baths  or  other  ap- 
plications of  water  externally,  and  finally  orthopedic  treatment 
and  curative  gymnastics.  Last  of  all  came  some  chapters  on 
the  medicinal  treatment  of  the  diseases  in  question.  Yet  in 
this  country  a  physician  runs  the  risk  of  being  considered  ec- 
centric— in  some  quarters  irregular  even — if  he  does  not  make 
drug  treatment  his  first  and  principal  resource  in  the  manage- 
ment of  the  digestive  disorders  as  well  as  in  all  other  dis- 
eases. 

Diseased  Stomachs  Need  Rest — When  there  is  acute  gen- 
eral disease  as  in  fever,  the  whole  body  is  rested  by  the  patient 
being  put  to  bed.  When  an  arm  or  leg  is  broken,  complete  rest 
of  the  affected  part  is  secured  by  putting  it  into  a  splint. 
When  the  stomach  is  seriously  damaged  either  by  injury  or 
disease,  it  also  imperatively  requires  rest  in  order  to  regain  its 
normal  condition;  but  it  is  impossible  to  give  it  absolute  rest 
and  yet  maintain  life  for  any  length  of  time. 

Hence  the  difficulties  attendant  upon  the  treatment  of  the 
chronically  diseased  digestive  organs.  Even  though  crippled, 
they  cannot  have  the  rest  which  would  allow  them  to  recover 
speedily.  But  by  means  of  diet  we  can  do  much  in  the  direc- 
tion of  resting  them.  When  the  disease  is  found  by  the  appro- 
priate tests  to  involve  the  stomach  exclusively  or  chiefly,  while 
the  liver,  pancreas,  and  intestinal  glands  are  normal,  we  can 
spare  the  suffering  part  very  much  by  prescribing  food  which 
will  tax  both  the  gastric  glands  and  musculature  as  little  as 
possible,  and  pass  rapidly  on  into  the  duodenum,  where  it  will 
meet  the  other  digestive  juices.  In  these  cases,  too,  you  should 
insist  upon  thorough  mastication,  so  as  to  get  all  the  help  pos- 
sible from  the  saliva. 

When,  on  the  other  hand,  the  stomach  is  shown  to  be  com- 
paratively healthy  and  other  parts  of  the  digestive  apparatus 
are  at  fault,  you  may  reverse  the  process,  and  give  foods  which 
can  be  digested  mainly  in  the  stomach. 


206  METHODS    OF    TREATMENT 

When  all  these  parts  are  involved,  as  is  too  often  the  case, 
we  may  still  afford  partial  rest  by  so  controlling  the  diet  as  to 
exclude  the  most  fermentable  articles  and  prevent  overburden- 
ing- of  the  afflicted  organs  from  an  excess  of  even  proper  food, 
or  by  food  which  is  either  naturally  tough  and  indigestible  or 
made  so  by  bad  cooking. 

Thus  it  may  be  seen  how  important  it  is,  if  curative  results 
are  to  be  obtained,  to  have  cases  of  indigestion  systematically 
examined  by  the  exact  methods  now  at  our  command,  and  the 
diet  carefully  adapted  to  them. 

Nor  can  this  adaptation  be  done  once  for  all.  Every  case 
may  profitably  be  studied  and  the  results  of  the  diet  and  treat- 
ment on  the  urine,  feces,  blood,  body  weight,  nerve  state,  etc., 
closely  watched.  But  with  the  earnest  and  conscientious  co- 
operation of  the  patient  and  the  patient's  friends  with  the 
efforts  of  the  physician,  very  much  can  be  accomplished  in 
even  many  of  the  most  unproniising  cases. 

Summary  of  Precautions. — To  sum  up,  the  chief  points  to 
bear  in  mind  in  advising  dyspeptics  regarding  their  eating, 
drinking,  etc.,  are  as  follows :  They  should  never  eat  a  hearty 
meal  when  very  tired,  vexed,  worried,  or  cold.  If  they  have 
been  exercising  severely,  they  should  lie  down  or  rest  in  some 
easy  position  for  half  an  hour  before  eating.  They  should  eat 
slowly  and  simply,  combining  few  things  in  one  meal,  and 
above  all  masticate  thoroughly  every  morsel  taken.  They 
should  also  endeavor,  so  far  as  possible,  to  dine  in  pleasant 
company  and  to  cultivate  a  cheerful  spirit  at  the  meal  hours. 
It  is  not  well  for  them  to  exercise  either  the  mind  or  body 
actively  for  at  least  half  an  hour,  and  better  an  hour,  after  their 
principal  meals,  especially  after  their  dinners.  They  must 
learn  to  use  their  saliva  for  the  purpose  of  moistening  and 
partly  digesting  their  farinaceous  food  instead  of  washing  it 
down  with  drinks.  Let  them  keep  their  feet  warm,  their  heads 
cool,  their  kidneys  active,  and  their  bowels  open,  by  simple 
natural  methods,  such  as  exercise,  drinking  freely  of  water  be- 


CONSIDERATIONS    CONCERNING    DIET  20/ 

tween  meals,  etc.,  avoiding  drugs  for  these  purposes  except 
when  especially  ordered  by  their  physician. 

Dietetic  Faults  the  Most  Frequent  Causes  of  Gastro- 
intestinal Disease. — Both  gastric  and  intestinal  affections  may 
be  due  to  the  prolonged  influence  of  cold  and  dampness  upon 
the  lower  extremities,  or  to  habits  of  indolence  which  prevent 
a  sufficient  use  of  the  muscles,  and  to  infections  of  various 
sorts ;  but  it  remains  true  that  a  considerable  proportion  of  the 
disorders  of  all  parts  of  the  alimentary  canal  are  dependent 
upon  dietetic  imprudences.  The  amount  or  quality  of  the  food 
or  drink,  or  the  times  or  manner  in  which  these  are  taken,  may 
be  unhygienic  and  injurious.  Manifestly  disease  which  has 
resulted  from  such  faults  in  diet  is  best  remedied  by  curing 
the  faults  upon  which  it  depends.  To  attempt  the  cure  of  such 
disease  by  administering  drugs,  by  the  application  of  electricity 
or  by  hydriatic  procedures,  without  correcting  the  dietetic 
error,  is  naturally  to  invite  failure. 

A  very  large  proportion  of  the  various  diseases  which  affect 
other  parts  of  the  human  body  also  are  directly  or  indirectly 
a  consequence  of  dietetic  faults. 

Therapeutic  Fasting. — At  different  times  and  by  different 
authorities,  all  possible  forms  of  dietotherapeutics,  from  com- 
plete fasting  to  forced  feeding,  have  been  employed  in  the 
treatment  of  disease.  Complete  fasting  for  limited  periods  is 
of  unquestionable  value  in  certain  diseased  conditions,  espe- 
cially in  the  early  stages  of  fevers  and  acute  inflammatory  con- 
ditions ;  and  the  thirty  to  forty-day  fasts  of  numerous  persons 
have  proved  that  strong,  well-nourished  individuals  may  often 
submit  even  to  such  prolonged  abstinence  from  food  without 
much  danger.  In  the  acute  inflammations  of  the  gastro- 
intestinal tract,  fasting  for  from  one  to  three  days  is  gen- 
erally safe  and  advantageous,  except  when  the  patient  is 
greatly  reduced  or  debilitated,  especially  when  the  case  is 
closely  watched  by  the  physician  and  a  trained  nurse.  In 
gastric  ulcer  the  withholding  of  food  by  the  mouth  is  now 
almost  universally  recommended  for  a  period  of  one  to  tw^o 


208  METHODS    OF    TREATMENT 

weeks,  nutriment  being  meanwhile  given  per  rectum.  Ex- 
clusive rectal  alimentation  in  acute  appendicitis  also  has  been 
strongly  urged  in  some  quarters. 

A^  lady  physician  once  narrated  to  me  that  she  had  been 
cured  of  a  stubborn  and  theretofore  incurable  fermentative 
dyspepsia  by  an  involuntary  fast  of  two  weeks,  necessitated  by 
having  been  shipwrecked  and  left  with  the  crew  and  several 
passengers  for  that  length  of  time  after  their  supply  of  food 
gave  out  before  relief  could  be  obtained.  This  physician 
asserted  that  thereafter  she  never  suffered  from  dyspepsia.  It 
seems  worth  considering  whether  in  intractable  cases  of  this 
kind  in  patients  who  are  not  much  debilitated  or  emaciated  the 
withholding  of  all  food  should  not  be  tried  for  a  short  time, 
when  they  can  be  kept  under  the  observation  of  their  physician. 

]\Iuch  has  been  written  lately  on  the  subject  of  fasting,  and 
many  careful  observations  have  been  made,  both  clinically 
and  in  the  laboratory,  on  fasting  persons.  Lusk's  work  on  the 
"  Science  of  Nutrition  "  ^  embodies  elaborate  reports  of  these. 
It  has  been  sufficiently  demonstrated  that  short  fasts  are  safe 
in  health  and  in  most  fairly  well-nourished  persons  suffering 
from  either  acute  or  chronic  ill-health  except  in  cases  of 
chronic  wasting  diseases,  such  as  tuberculosis  and  diabetes,  in 
which  aggravation  may  result,  the  excretion  of  sugar  in  the 
latter  being  often  thereby  increased.  Lusk  states  that  "  if  the 
organism  has  previously  been  well  nourished,  the  fasting 
metabolism  is  remarkably  even,  about  13  per  cent,  of  the  total 
energy  being  derived  from  proteid  and  87  per  cent,  from  fat." 
The  nitrogen  elimination  usually  decreases  rather  steadily,  but 
some  observers  ha^•e  noted  that,  after  about  the  twentieth  day, 
a  rapid  increase  may  occur,  which  they  call  the  premortal  rise. 
In  the  latter  days  of  prolonged  fasts,  too,  the  excretion  of 
acetone  and  ft  oxybutyric  acid  has  been  found  to  be  markedly 
increased,  and  albumen  is  of  frequent  occurrence,  according 
to  Lusk,  in  the  starvation  urine  of  man  and  animals-. 

^"The  Elements  of  the  Science  of  Nutrition."   By  Graham  Lusk.    Phila. 
and  London:  W.  B.  Saunders  Company.     1906. 


CONSIDERATIONS    CONCERNING    DIET 


209 


Evidently,  therefore,  prolonged  fasts  are  not  safe,  especially 
in  persons  who  are  much  below  their  normal  weight,  unless  the 
state  of  their  circulation  and  metabolism  is  carefully  watched 
by  a  competent  physician  so  that  the  administration  of  food 
can  be  resumed  if  signs  of  danger  appear.  On  the  other  hand, 
under  the  proper  conditions,  an  absolute  fast  of  five  to  ten  days, 
perhaps  longer,  in  persons  with  unimpaired  hearts  and  a  nearly 
normal  amount  of  adipose  tissue,  may  be  safely  undertaken  in 
the  hope  of  assisting  markedly  the  appropriate  remedies  to  cure 
or,  at  least,  greatly  improve  such  conditions  as  microbic  infec- 
tion of  the  stomach  or  intestines,  gastric  or  duodenal  u]':er 
and  hyperchlorhydria  as  well  as  the  other  affections  associated 
with  an  excessive  functioning  of  any  of  the  glands  in  the  di- 
gestive tract,  and,  in  short,  for  most  of  the  results  of  over- 
eating, which  are  so  exceedingly  prevalent. 

The  following  table,  from  a  standard  authority,  will  serve 
you  in  selecting  the  proper  amounts  of  the  various  articles  to 
meet  the  requirements  of  nutrition. 

THE  PROPORTIONS  OF  THE  SEVERAL  INGREDIENTS  IN 
THE  DIFFERENT  FOOD  ARTICLES 


Food  Material 
Edible  Portion 

Proteid 
Per 

cent. 

Fat 
Per 
cent. 

Carbo- 
hydrates 
Per  cent. 

Salts 
Per 
cent. 

Fuel  Value 

of 
one  pound 
in  calories 

Ribs  of  beef          .... 

15-4 

35-6 

0.9 

1.790 

Sirloin  steak 

18.5 

20.5 

I.O 

1,270 

Round      " 

20.5 

10. 1 

1.2 

805 

Veal,  shoulder     . 

20.2 

9.8 

1.2 

790 

Mutton,  shoulder 

18. 1 

22.4 

0.9 

1,280 

"         breast     . 

14.2 

47-2 

1.0 

2,215 

leg 

18.3 

19 

0.9 

1,140 

Lamb,  shoulder  . 

17-5 

29.7 

1.0 

1,580 

^, '.',     ^^S    • 

18  9 

15-3 

I.I 

1,000 

Chicken 

24  4 

2 

1.4 

540 

Turkey- 

23.9 

8.7 

1.2 

810 

Hen's  egg     . 

14.9 

10.5 

0.8 

720 

Ham,  Salted  and  Smoked 

16.7 

39-1 

2.7 

1,900 

Shad     .... 

18.6 

9-5 

1-3 

745 

Whitefish      . 

22.1 

6.5 

1.6 

685 

vSalmon 

21.6 

13-4 

1-4 

965 

Lake  trout    . 

18.2 

II. 4 

1.3 

820 

Brook  trout  . 

19 

2.1 

1.2 

440 

Mackerel 

18.2 

7.1 

1-3 

640 

Bluefish 

19 

1.2 

1-3 

405 

Butter-fish    . 

, 

17.8 

II 

1.2 

795 

Black  bass  . 

20,4 

i'7 

1.2 

450 

210 


METHODS    OF    TREATMENT 


THE  PROPORTIONS  OF  THE  SEVERAL  INGREDIENTS  IN 
THE  DIFFERENT  FOOD  AR.'l'lCl.E?>—Contmtied 


Food  Material 

Proteid 

Fat 

Carbo- 

Salts 

Fuel  Value 
of 

Per 

Per 

hydrates 

Per 

Edible  Portion 

cent. 

cent. 

Per  cent. 

cent. 

one  pound 
in  calories 

Cod,  whole 

15-8 

0.4 

1.2 

310 

Halibut 

18.3 

5-2 

I.I 

560 

Oysters 

6.1 

1.2 

3-6 

2 

230 

Clams  . 

6-5 

0.4 

4.2 

2-7 

215 

Lobster 

14.6 

1-9 

1-7 

350 

Crab     . 

17.8 

2 

3-1 

415 

Terrapin 

21 

3  5 

I 

540 

Green  turtle 

18.5 

0.5 

1.2 

305 

Milk      . 

3-6 

4 

4-7 

0.7 

325 

Butter  . 

I 

85 

0 

5 

3 

3.615 

Cheese,  full  cream 

28.3 

35-5 

I 

8 

4.2 

2,070 

"         skim-milk 

38.4 

6.8 

8 

9 

4.6 

1,165 

Potatoes 

2.1 

0.1 

17 

9 

I 

375 

Sweet  potatoes    . 

1-5 

0.4 

26 

I 

530 

Red  beets     . 

1-5 

0.1 

8 

8 

I.I 

195 

Turnips 

1.2 

0  2 

8 

2 

I 

185 

Carrots 

i.r 

0.4 

8 

9 

I 

205 

Squash 

0.9 

0.2 

10 

I 

0.7 

215 

Cabbage 

2.4 

0.4 

5 

3 

1-4 

155 

Cauliflower  . 

1.6 

0.8 

5 

0.8 

155 

Spinach 

2.T 

0.5 

3 

I 

1-9 

120 

Asparagus    . 

1.8 

0.2 

3 

3 

0.7 

105 

Tomatoes     . 

0.8 

0.4 

2 

5 

0.3 

80 

Green  peas  . 

4.4 

0.5 

16 

I 

0.9 

400 

String  beans 

2.2 

0.4 

9 

5 

0.7 

235 

Lima  beans 

7-1 

0.7 

22 

1-7 

570 

Green  sweet  corn 

2.8 

I.I 

14 

2 

0.7 

300 

Haricots  verts 

I.r 

0.1 

2 

6 

I.I 

70 

Baked  beans,  canned 

7-1 

3.2 

20 

3 

2.2 

645 

Apples 

0.3 

0.4 

15 

9 

0.2 

320 

Grapes 

1.6 

I  7 

21 

3 

0.6 

500 

Banana 

1.4 

1.4 

29 

S 

I.I 

640 

Pineapple     . 

0.4 

0.3 

9 

7 

0.3 

200 

Rice      . 

7-4 

0.4 

79 

4 

0.4 

1,630 

Beans,  dried 

23.1 

2 

59 

2 

3.1 

1,615 

White  hominy 

8-3 

o.-f 

77 

4 

0.4 

1,620 

Oatmeal 

14-7 

1.1. 

68 

4 

2 

1,845 

Pearl  barley 

8.4 

0.7 

78 

I 

I 

1,635 

Entire  wheat 

II. 9 

1-7 

74 

6 

1.4 

1,680 

Buckwheat  . 

6.9 

1-4 

76 

I 

I 

1,605 

Buckwheat  farina 

3-3 

0.3 

84 

8 

0.4 

1,650 

Wheat  bread 

8.8 

1-7 

56 

3 

0.9 

1,280 

Graham    " 

9-5 

1-4 

53 

3 

1.6 

1,225 

Rye 

8.4 

0.5 

59 

7 

1.4 

1,285 

Soda  crackers 

10  3 

94 

70 

5 

1.8 

1,900 

Oyster  crackers   . 

II-3 

4.8 

77 

5 

2.5 

1.855 

Oatmeal     " 

10.4 

i3.7 

69 

6 

1.4 

2,065 

Graham      " 

9.8 

13.6 

69 

7 

19 

2,050 

Starch  . 

97 

8 

0.2 

1,820 

Sugar,  granulated 

97 

3 

0.2 

1,820 

Molasses 

73 

I 

.23 

1,360 

CONSIDERATIONS    CONCERNING    DIET  211 

In  ordering  a  diet,  you  would  best  follow  pretty  nearly  at 
first  the  tables  given  in  the  preceding  lecture,  except  to  lessen 
decidedly  the  proportion  of  the  proteids  or  albuminoid  foods, 
having  regard  to  the  sex  and  occupation  of  the  patient.  Then 
when  the  latter  has  learned  to  chew  all  food  long  and  thor- 
oughly, you  might  try,  in  well-nourished  cases,  whether  the 
weight  cannot  be  maintained  upon  smaller  amounts  so  as  to 
avoid  the  dangers  of  overfeeding. 

The  Arrangement  of  Meals  with  Relation  to  Rest  and 
Exercise. — A  matter  of  much  practical  importance  in  relation 
to  diet  is  the  arrangement  of  the  times  for  meals.  This  might 
have  been  appropriately  considered  in  the  preceding  lecture 
under  Prophylaxis,  but  its  discussion  will  be  ec|ually  in  place 
here.  In  Germany  and  in  some  other  parts  of  Europe  it  is  the 
custom  to  take  a  very  light  repast  upon  arising,  and  then  at 
eleven  or  twelve  o'clock  to  take  what  is  called  a  second  break- 
fast, which  is  a  more  substantial  meal.  Then  a  hearty  dinner 
is  eaten  at  from  three  to  six  o'clock,  varying  with  the  locality 
and  the  social  position  of  the  person.  In  most  places  a  supper 
is  taken  later  in  the  evening.  In  the  United  States  the  custom 
as  to  the  number  and  character  of  meals  varies  greatly  in  differ- 
ent localities  and,  naturally,  with  different  classes  of  people. 
Not  a  few  persons  eat  two  meals  a  day  only,  both  of  them 
usually  substantial  ones,  at  8  to  9  a.  m.,  and  from  4  to  6 
p.  M.,  as  a  rule.  A  majority  of  Americans  eat  three  meals 
daily,  beginning  with  a  hearty  breakfast  at  six  to  eight  o'clock, 
comprising  eggs  or  meat  and  some  form  of  carbohydrate  food 
with  coffee  or  one  of  the  cereal  imitations  of  it.  The  wealthier 
classes,  in  the  East  especially,  commonly  eat  a  luncheon  more 
or  less  generous  in  the  middle  of  the  day,  and  dinner  at  6 
to  7  p.  M.  Most  farmers,  and  working  people  generally, 
who  make  up  a  very  large  majority  of  the  total  population, 
take  a  hearty  meal,  including  usually  meat,  in  the  middle  of 
the  day,  and  supper,  ordinarily  a  substantial  one  including 
meat  again,  in  the  evening.  A  few  persons,  following  the 
teaching  of  a   Pennsylvania  physician,   omit  breakfast  alto- 


212  METHODS    OF    TREATMENT 

gether,  taking  their  first  meal  at  from  eleven  to  twelve  o'clock, 
and  a  second  one  when  the  day's  work  is  over,  at  six  or  some 
time  thereafter. 

Advantages  have  been  claimed  for  each  of  these  methods 
of  distributing  the  daily  meals.  The  last-mentioned 
one  possesses  marked  disadvantages  in  that  the  two  neces- 
sarily rather  hearty  meals  taken  for  the  maintenance  of 
the  body  during  twenty-four  hours  are  eaten  so  nearly  together 
within  a  period  of  six  to  seven  hours.  A  breakfast  delayed 
until  midday  must  perforce  be  a  generous  one,  which  might  well 
be  expected  to  interfere  somewhat  with  the  working  power  of 
an  individual  during  what  must  be  for  most  persons  the  active 
afternoon  hours.  Two  meals  a  day  will  often  suit  sedentary 
persons  best,  but  they  should  be  eight  to  ten  hours  apart,  and 
the  luncheon  or  midday  dinner  is  the  meal  which  can  be  most 
advantageously  omitted. 

Whether  two  meals,  or  four  or  five  meals,  will  nourish  the 
system  best  and  with  least  embarrassment  to  the  other  func- 
tions besides  those  engaged  in  the  work  "of  digestion,  can 
doubtless  not  be  settled  in  the  same  way  for  all. 

Men  and  women  who  work  with  their  muscles  usually  need 
at  least  three  meals,  and  these  should  be  as  equally  divided 
as  possible  throughout  the  waking  hours.  The  idle  and  lux- 
urious classes,  when  in  good  health,  do  not,  as  a  rule,  actually 
need  more  than  three  meals  in  the  twenty-four  hours,  and 
very  many  of  them  would  do  better  with  two  only.  When,  as 
usual,  their  time  for  retiring  is  from  eleven  to  one  o'clock  at 
night,  it  is  doubtless  best  that  their  largest  meal — the  dinner 
— should  be  taken  in  the  early  evening.  If  they  are  regularly 
up  until  midnight  or  later  they  may  properly  enough  take  a 
very  light  additional  repast  before  retiring;  but  only  if  it  be 
taken  regularly  and  at  the  same  hour  every  night.  They  will 
naturally,  with  these  habits,  breakfast  late,  rarely  earlier  than 
nine  o'clock,  and  if  they  take  any  luncheon  at  all  it  should  be 
a  very  small  one  at  i  or  2  p.  m. 

These  general  statements  as  to  customs  and  the  food  re- 


CONSIDERATIONS    CONCERNING    DIET  213 

quiremeiits  of  persons  in  health  having  been  premised,  it  is  in 
place  to  add  a  few  suggestions  of  a  general  character  as  to 
how  patients  with  a  stomach  or  bowel  disease  should  arrange 
their  meals.  It  is  necessary  to  divide  such  persons  into  two 
distinct  classes :  First,  those  who,  in  spite  of  their  ailment,  are 
obliged  to  continue  actively  at  work;  and,  second,  those  who 
can  dispose  of  their  time  as  is  most  pleasant  or  healthful  for 
them.  As  to  the  latter,  it  may  be  said  at  once  that,  as  a  rule, 
•it  is  best  for  them  to  eat  their  heartiest  meal  in  the  middle  of 
the  day,  so  that  it  shall  be  fully  digested  long  before  the  hour 
for  retiring,  which,  in  their  case,  should  generally  be  an 
early  one.  For  many  of  these  well-to-do  invalids  who  have 
weak  digestive  power,  the  best  arrangement  will  be  two  to 
three  small  meals  with  two  or  more  very  light  repasts  between 
them,  so  that  the  digestive  organs  may  be  at  no  time  over- 
burdened. Many  a  weak  stomach  will  digest  easily  and 
quickly  quite  a  small  meal,  while  it  would  be  embarrassed 
seriously  by  a  large  one. 

The  poor  dyspeptic  who  must  remain  at  his  desk  or  other 
work  eight  to  ten  hours  daily,  or  the  wealthy  one  who  insists 
upon  attending  to  business  or  devoting  himself  actively  to  any 
pursuit  which  closely  occupies  his  time  during  the  day,  must 
necessarily  have  his  meals  arranged  with  great  care.  As  a 
rule,  his  breakfast  should  be  substantial,  and  it  will  often  be 
best  for  him  to  take  a  plain  dinner  in  the  middle  of  the  day, 
provided  he  can  have  time  enough  to  eat  it  without  hurrying, 
and  a  little  rest  after  it,  since  his  supper  can  then  be  a  much 
lighter  meal  than  would  otherwise  be  necessary,  and  his  sleep 
will  likely  be  much  less  disturbed  and  more  refreshing.  In 
many  instances,  however,  the  digestion  is  so  poor  that  the 
patient,  for  several  hours  after  eating  such  a  mixed  meal  as  a 
dinner,  is  incapacitated  for  any  concentrated  mental  effort,  and 
in  the  case,  therefore,  of  a  person  thus  afflicted,  whose  occupa- 
tion calls  for  brain  work  during  the  afternoon  hours,  it  would 
be  much  wiser  to  take  luncheon  at  midday  and  as  simple  a  din- 
ner as  possible  at  night.    It  may  easily  be  seen  that  the  problem 


214  METHODS    OF    TREATMENT 

is  a  somewhat  intricate  one,  and  that  no  hard-and-fast  rule  can 
be  made  which  will  suit  all  persons.  Here  especially  the  phy- 
sician must  individualize  his  cases  and  make  his  dietetic  direc- 
tions correspond  to  the  needs  of  each  particular  case. 

Regularity  in  Times  of  Eating  Essential. — In  whatever  way 
the  times  for  meals  may  be  arranged  in  the  case  of  persons 
who  have  either  inherited  or  acquired  a  delicacy  of  constitution 
or  tendency  to  indigestion,  the  meals  must  be  taken  with  the 
utmost  possible  regularity  at  the  same  hours  every  day.  No 
hygienic  rule  is  more  important  than  this  for  such  persons, 
and  indeed,  if  they  could  only  be  made  to  believe  it,  for  all 
persons.  Horsemen  know  that  irregularity  in  the  times  of 
feeding  their  horses  will  injure  them  and  do  not  permit  any 
carelessness  in  this  regard  on  the  part  of  their  employees.  But 
certain  of  our  society  people  seem  to  consider  themselves  above 
all  hygienic  laws  in  the  matter  of  eating  and  drinking,  taking 
their  last  meal  of  the  day  sometimes  at  6  to  7  p.  m.^  but 
on  several  of  the  evenings  each  week  consuming  indigestible 
suppers  at  any  hour,  from  ten  to  twelve,  that  may  happen  to 
suit  best  their  entertainers  or  the  character  of  the  entertain- 
ment. Physicians  understand  well  enough  that  this  is  ruin- 
ous to  the  digestion  of  all  but  the  very  strongest,  and  that 
even  these  must  inevitably  pay  the  penalty  also,  only  a  little 
later,  and  in  the  form  of  heart  or  kidney  disease  or  apoplexy, 
if  not  in  that  of  indigestion. 

For  those  who  find  that  they  can  eat  anything,  at  any  time 
without  paying  the  penalty  as  they  go  along,  no  reform,  of 
course,  is  possible  or  at  least  likely ;  but  for  the  others,  among 
whom  are  to  be  included  a  large  proportion  of  the  intellectual 
classes,  the  lawyers,  clergy,  artists,  and  literary  people,  many 
of  whom  are  very  social,  and  some  of  whom  are  among  the 
brightest  ornaments  of  society,  it  does  seem  as  though  some- 
thing might  be  done.  It  ought  to  be  possible  for  this  large  and 
very  influential  class  of  society  to  assert  itself  in  some  effective 
way  which  would  protect  its  members  from  the  well-nigh  irre- 
sistible temptation  to  transgress  the  laws  of  health — one  might 


CONSIDERATIONS    CONCERNING    DIET  215 

say  almost  the  necessity  of  eating  and  drinking  unhygienically, 
if  they  would  not  make  themselves  unpleasantly  conspicuous — 
without  obliging  them  to  forego  all  social  enjoyments. 

A  majority  of  these  intellectual  people,  who  are  prone  to 
have  indigestion  when  they  transgress  health  rules,  have  a 
tendency  to  hyperchlorhydria ;  their  gastric  glands  are  easily 
excited  to  oversecretion.  When  such  persons  are  offered 
tempting  viands  on  a  festive  occasion  at  an  hour  when  not  only 
their  stomachs  but  those  of  all  the  others  should  be  resting, 
they  are  frequently  amiable  enough  to  make  a  feint  of  eating 
just  a  little  something  for  the  sake  of  appearances — not  to 
seem  to  frown  in  disapproval  of  what  the  others  are  doing. 
Perhaps  they  are  able  to  find  in  the  menu  some  apparently 
innocent  thing  like  delicate  pieces  of  bread  and  butter  or  bis- 
cuits, and  they  resolve  just  to  nibble  a  little  at  one  of  these. 
The  result  is  such  a  rapid  pouring  out  of  gastric  juice  as  speed- 
ily constrains  them  to  go  on  and  eat  heartily  of  whatever  can 
be  had,  with  the  result  often  of  a  sleepless  night  and  utter 
unfitness  for  the  next  day's  duties. 

I  have  often  wondered  if  it  would  not  be  feasible  for  the 
many  agreeable  people  of  this  kind  who  are  in  society  to  get 
together,  declare  their  independence  of  Dame  Fashion  so  far 
as  regards  the  late  suppers,  and  flock  by  themselves  at  parties 
when  the  eating  time  comes  around,  or  perhaps  get  up  an  occa- 
sional social  affair  of  their  own  at  which  there  should  be  nothing 
additional  to  the  usual  festivities  except  "  a  feast  of  reason  and 
flow  of  soul."  In  the  meantime,  however,  you  will  favor  your 
dyspeptic  patients  most  by  making  your  prohibition  of  eating 
out  of  season,  whether  the  food  served  be  good  or  bad,  as  em- 
phatic as  possible.  The  more  imperative  your  commands  the 
easier  it  will  be  for  them  to  withstand  the  temptation  placed 
before  them. 


LECTURE  XVIII 

THE  DIET    IN    IRRITATIVE    AND    ATONIC 
CONDITIONS 

Classification  of  Diseases  with  Regard  to  Dietetic  Treat- 
ment.— All  the  conditions  of  impaired  health  in  which  there 
is  indigestion  may,  for  the  purpose  of  dietetic  treatment,  be 
divided  into  two  great  classes.  One  comprises  the  affections 
in  which  there  is  disease  in  some  part  of  the  digestive  tract. 
This  may  be  inflammatory  or  degenerative,  or  may  merely  con- 
sist of  a  persistently  increased  or  diminished  functional  activ-- 
ity  on  the  part  of  the  muscular  apparatus  or  secreting  cells, 
or  both. 

The  other  class  includes  affections  of  the  nervous,  circu- 
latory, respiratory,  or  genito-urinary  system,  accompanied  by 
reflex  or  sympathetic  derangements  of  digestion  of  a  transient 
or  variable  character.  In  the  latter  class,  the  digestive  organs 
themselves  may  be  healthy,  and  the  diet  to  be  prescribed  then 
is  that  appropriate  to  the  disease  existing  elsewhere.  If  this 
be  tuberculosis  or  a  true  neurasthenia  due  to  overtaxed  ener- 
gies and  not  to  lithjemia,  the  diet  should  be  generous  and  may 
be  often  relatively  rich,  or  even  what  would  usually  be  con- 
sidered indigestible,  regardless  of  the  symptoms  referred  to 
the  gastro-intestinal  tract. 

It  is  otherwise  with  the  former  class — the  diseases  involving 
some  part  of  the  digestive  apparatus  itself.  Of  these  two  sub- 
divisions may  be  made :  those  with  increased,  and  those  with 
decreased  functional  activity.  Here  you  will  need  either  to 
stimulate  or  soothe,  or  more  frequently  still,  perhaps,  to  spare 
the  affected  organ  by  suitable  remedies  and  foods.  To  spare 
an  organ  is  to  lessen  its  work  in  order  that  Nature  may  be 

216 


DIET    IN    IRRITATIVE    CONDITIONS  21/ 

better  enabled  to  bring  about  restorative  changes.  When  you 
put  to  bed  a  patient  with  typhoid  fever,  or  nervous  prostra- 
tion, all  the  organs  are  spared  as  much  of  their  usual  work  as 
possible.  By  means  of  diet,  just  as  by  medicines  or  the  me- 
chanical methods  of  treatment,  you  can  either  stimulate  or 
depress  the  functional  activity  of  various  structures  and  by  the 
same  means — a  proper  selection  of  foods — you  can  often  do  that 
which  can  seldom  be  done  by  any  drug,  to  wit :  save  or  spare 
a  crippled  organ,  thus  affording  it  at  least  relative  rest,  even 
while  the  other  parts  of  the  body  may  continue  active. 

The  Diet  in  Irritative  Conditions. — But  in  all  cases  with 
irritative  conditions  in  the  digestive  organs,  especially  in  the 
more  stubborn  cases  of  excessive  HCl  secretion  (hyperchlor- 
hydria),  whether  an  ulcer  is  demonstrable  or  not,  you  may 
sometimes  cure  rapidly  by  carrying  out  the  accepted  treatment 
for  gastric  ulcer,  which  is  to  place  the  patient  for  a  time  at 
complete  rest  in  bed,  with  at  first  either  no  food  by  the  mouth 
or  only  small  amounts  of  the  blandest  liquid  nutriment  in  that 
way,  supplementing  this  by  rectal  feeding.  I  have  been  much 
impressed  by  the  fact  that  some  of  such  cases,  so  long  as 
treated  for  simple  hyperchlorhydria  with  the  usual  drugs  and 
diet,  but  allowed  to  go  about  their  business  or  pleasures,  prove 
exceedingly  obstinate  and  yet  respond  promptly  when,  after 
the  symptoms  have  begun  to  awaken  the  suspicion  of  gastric 
ulcer,  the  patients  have  been  put  to  bed  with  only  rectal  feeding 
for  a  week  or  two,  followed  by  a  strictly  liquid  diet  by  the 
mouth,  very  gradually  increased. 

Typical  examples  of  the  irritative  disorders  demanding  sed- 
ative remedies  and  a  sedative  diet,  or  functional  rest,  are,  in 
the  stomach,  round  ulcer,  h3^perchlorhydria,  and  acid  gastric 
catarrh,  and  in  the  intestines,  diarrhea,  and  probably  also  most 
cases  of  spastic  constipation,  as  well  as  all  the  forms  of  enteritis 
and  colitis.  Stimulant  or  irritant  foods  and  food  acces- 
sories (or  indigestible  foods,  which  are  irritating  in  propor- 
tion to  their  lack  of  digestibility),  including  many  vegetables, 
especially   cabbage,    onions,    and    radishes,    acid    fruits,    most 


2l8  METHODS    OF    TREATMENT 

of  the  uncooked  vegetables  and  fruits,  the  spices,  and  most 
of  the  sharper  condiments,  and  the  meats  in  the  form 
usuahy  eaten,  are  especiahy  hkely  to  aggravate  the  class  of 
gastro-intestinal  diseases  which  are  characterized  or  accom- 
panied by  irritative  conditions. 

On  the  other  hand,  the  blandest  and  least  stimulating  ali- 
ments, such  as  milk  and  whey,  as  well  as  rice  and  other  fari- 
naceous preparations,  when  well  insalivated  by  thorough  mas- 
tication, taken  in  small  quantities  at  a  time,  and  especially 
when  the  starch  has  been  previously  dextrinized  by  prolonged 
baking,  conduce  more  to  the  cure  of  the  same  diseases.  These 
starch  foods  should,  in  all  cases  of  hyperacidity,  be  taken  early 
in  the  meal  and  never  at  the  end  of  it  as  in  the  form  of  dessert, 
unless  the  dextrinization  has  been  very  complete ;  otherwise,  no 
matter  how  well  insalivated  such  food  is,  the  high  acidity  of 
the  stomach  contents  towards  the  end  of  the  meal  stops  at  once 
the  process  of  starch  coni'ersion. 

Meats  in  HCl  Excess. — The  meats,  however,  though  known 
to  stimulate  secretion  more  than  other  foods,  are  recommended 
by  man}^  authorities  in  conditions  associated  with  excessive 
secretion  of  HCl  because  they  combine  or  use  up  more  of  the 
surplus  acid  and  thus  often  seem  to  lessen  the  discomfort  after 
meals  more  than  other  forms  of  nourishment,  and  for  the  fur- 
ther reason  that  the  starches  are  theoretically  less  digestible 
in  such  hyperacid  conditions.  These  reasons  for  adopting  a 
stimulating  diet  in  a  disease  peculiarly  characterized  by  irri- 
tation might  be  convincing  but  for  the  fact  that  such  a  diet 
tends  to  intensify  and  perpetuate  the  underlying  morbid  state 
of  the  secreting  cells  so  that  the  temporary  palliation  of  the 
symptoms  is  dearly  bought.  Moreover,  clinical  experience  has 
shown  that  in  these  hyperchlorhydric  cases  starch  foods  taken 
at  the  beginning  of  small  or  very  moderate  meals  and  thor- 
oughly chewed  so  as  to  obtain  the  full  amylolytic  effect  of  the 
saliva,  may  generally  be  made  to  digest  and  agree  well,  espe- 
cially when,  by  means  of  full  alkaline  medication  or  other 
appropriate  treatment,   the   irritated   condition  of  the  glands 


DIET    IN    IRRITATIVE    CONDITIONS  219 

is  at  the  same  time  overcome  as  rapidly  as  possible.  Indeed,  in 
the  hundreds  of  cases  showing  an  excess  of  HCl  which  have 
been  treated  at  my  offices  during  the  last  few  years,  the  gastric 
contents  brought  up  for  testing  were  nearly  always  in  a  per- 
fect solution,  even  though  the  analysis  indicated  that  the  proc- 
ess of  starch  conversion  had  not  been  carried  so  far  as  it 
normally  should  be  in  the  stomach. 

But,  as  there  are  exceptions  to  all  rules,  so  in  these  irritative 
conditions  with  excessive  HCl  secretion,  you  will  often  en- 
counter cases  complicated  with  much  fermentation  of  the 
starch  and  saccharine  foods  (carbohydrates)  and  in  these  it  is 
well  to  let  the  diet  at  first  consist  largely  of  the  blander  nitrog- 
enous foods,  such  as  soft-boiled  eggs  and  the  juice  pressed 
out  of  beefsteak,  meat  powders,  or  finely  hashed  steak  with 
sometimes  plenty  of  fat  in  some  palatable  form  (since  this 
lessens  HCl  secretion),  and  only  a  minimum  of  the  carbohy- 
drates. The  organic  acids  produced  by  fermentation,  when 
present  in  large  amounts  in  the  stomach,  seem  to  act  as  an 
irritant  in  marked  degree  to  the  secretory  structures,  and  thus 
in  these  exceptional  cases  may  increase  or  even  provoke  a 
hypersecretion  of  HCl  as  surely  as  tough,  indigestible  articles, 
or  stimulating  foods,  such  as  meats  in  the  ordinary  forms. 

HCl  doubtless  possesses  important  germicidal  properties  as 
against  some  bacteria,  but  yeast  fungi  certainly  flourish  in  its 
presence,  and  other  organisms  that  produce  fermentation  in 
the  stomach  in  many  cases  are  not  inhibited  by  even  a  large 
excess  of  it  to  any  efficient  extent.  Thus,  w'hile  certain  gen- 
eral rules  apply  in  the  selection  of  a  diet  for  any  given  case  of 
gastric  or  intestinal  disease,  it  is  necessary  constantly  to  indi- 
vidualize, to  study  each  case  by  itself — indeed,  on  account  of 
idiosyncrasies,  it  is  often  needful  to  study  the  response  of  each 
digestive  apparatus  to  each  special  article  of  food  which  is  to 
be  depended  upon  as  a  chief  part  of  the  nourishment  for  any 
considerable  time. 

The  Diet  in  Atonic  Conditions. — Turning  now  to  the  oppo- 
site class   of  gastro-intestinal   cases,   those   characterized  by 


220  METHODS    OF    TREATMENT 

atonic  conditions  with  symptoms  of  depression — deficient 
functional  activity — as  in  atrophy,  achylia,  or  hypochlorhy- 
dria,  chronic  asthenic  catarrh,  and  carcinoma  of  the  stomach, 
gastric  motor  insiii^ciency,  dilatation  of  the  stomach,  chronic 
atonic  constipation,  etc.,  a  somewhat  different  kind  of  diet 
needs  to  be  prescribed. 

In  the  atonic  cases  of  gastric  and  intestinal  disease  not 
accompanied  by  catarrhal  inflammation,  whether  the  atony 
involves  chiefly  the  glandular  or  muscular  structures,  the  diet 
should  be  first  of  all  as  digestible  and  nourishing  as  possible, 
and  if  at  the  same  time  it  be  stimulating,  the  results  in  bringing 
up  nutrition  will  usually  be  all  the  better.  Animal  broths,  and 
even  the  much  condemned  beef  tea,  may  prove  of  service  here 
as  being  capable  of  stimulating  the  appetite  and  increasing  the 
ability  of  the  various  organs  to  digest  more  nourishing  articles 
of  food.  The  fermented  products  of  milk,  such  as  kumyss, 
kefir,  matzoon,  etc.,  often  suit  very  well  in  these  conditions ; 
and  if  the  lighter  alcoholic  beverages,  such  as  claret,  Rhine 
wines,  or  possibly  even  port  and  sherry,  are  ever  to  be  recom- 
mended in  gastro-intestinal  cases,  it  should  be  especially  in 
these  atonic  forms  of  them.  The  fermented  liquors,  such  as 
beer,  ale,  porter,  brown  stout,  and  the  popular  liquid  malt 
extracts  which  are  sometimes  more  carefully  brewed,  have 
also  a  certain  tonic,  or,  at  least,  stimulant  action  upon  the  appe- 
tite, besides  possessing  some  diastasic  property  and  a  very  slight 
content  of  real  nutriment.  In  small  doses  they  can  undoubt- 
edly be  of  service  temporarily  in  such  atonic  cases  in  which 
there  is  not  too  great  a  tendency  to  fermentation ;  possibly, 
also,  in  a  limited  number  of  similar  cases  in  which  there  is 
considerable  fermentation,  dependent  chiefly  upon  a  lowered 
tone  in  the  nerve  centers  presiding  over  the  digestive  proc- 
esses. 

In  certain  affections  of  the  alimentary  canal,  especially  in 
chronic  asthenic  catarrh  of  the  stomach  or  duodenum,  with 
good  rnotor  power  and  with  normal  pancreatic  and  hepatic 
secretion,  you  may  expect  favorable  results  from  such  stimu- 


DIET    IN    IRRITATIVE    CONDITIONS  221 

lating  and  yet  very  digestible  articles  of  diet  as  broths,  meat 
juice,  meat  powders,  especially  Mosquera's  Beef  ]\Ieal,  and 
scraped  or  hashed  lean  beefsteak,  and,  in  the  less  severe  cases, 
tender  lean  meats  in  the  usual  forms,  especially  beef,  mutton, 
lamb  or  poultry,  roasted,  broiled,  or  thoroughly  stewed.  A 
predominantly  nitrogenous  diet  wdiich  is'"  at  the  same  time 
easily  digested,  keeps  down  fermentation,  and  will  maintain 
nutrition  well  enough  for  short  periods — say  four  to  six 
weeks,  notwithstanding  that  it  furnishes  temporarily  much 
more  proteids  than  the  normal  one-tenth  to  one-fifth  part,  and 
much  less  carbohydrates  than  the  normal,  which  is  from  four 
to  five-sixths  of  the  whole  amount.  The  normal  one-tenth  part 
of  fats  may  be  supplied,  and  even  much  exceeded,  with  such 
an  anticatarrhal  diet,  when  it  is  found  to  agree,  but  sometimes 
this  proportion  of  fats  will  increase  fermentation  so  much  as 
to  retard  the  cure.  With  this  diet,  a  small  amount — three, 
four,  or  five  slices  daily — of  moderately  stale  bread  and  butter 
can  usually  be  allowed,  and  in  those  cases  without  HCl  excess 
it  need  not  be  toasted  or  in  the  form  of  zwieback,  the  particles 
of  which  are  too  hard  and  gritty  for  easy  solution  in  the  stom- 
ach, in  consequence  of  which  there  often  result  from  such  food 
increased  flatulence  and  constipation.  Most  hard  biscuits 
(crackers)  are  open  to  the  same  objection,  beside  the  danger 
of  having  been  kept  too  long. 

A  free  use  of  water,  preferably  taken  rather  hot,  is  an 
almost  indispensable  accompaniment  of  such  a  nitrogenous 
anticatarrhal  regimen  in  order  to  maintain  an  efficient  elimina- 
tion through  all  the  emunctories,  as  well  as  to  cleanse  away  the 
accumulations  of  mucus  from  the  affected  membranes.  When, 
however,  in  these  or  in  any  other  cases,  the  gastric  motility  is 
much  impaired  as  a  result  of  other  causes  than  hyperacidity, 
the  fluids  of  all  kinds  must  be  strictly  limited ;  gastric  lavage 
and  flushing  of  the  colon,  more  ef^cient  methods  when  pru- 
dently managed,  must  then  take  the  place  of  the  copious  water- 
drinking. 

A  milk  diet  is  the  favorite  resource  of  many  routine  practi- 


222  METHODS    OF    TREATMENT 

tioners  in  all  catarrhal  or  suspected  catarrhal  cases,  for  under 
the  still  prevalent  guessing  methods  the  diagnosis  is  very 
©ften  wrongly  made.  It  suits  sometimes  admirably,  but  quite 
as  often  fails  or  aggravates,  especially  when  there  is  excessive 
lactic  fermentation  and  in  the  cases  with  deficient  motor  power 
in  the  stomach.  Eskay's  Food  or  peptonized  milk  may  succeed 
when  plain  milk  fails,  and  Plasmon  can  often  be  added  to  the 
latter  with  advantage,  making  a  more  nourishing  but  still 
easily  digestible  and  non-irritating  food. 

Some  such  restricted  diet  is  usually  advisable  in  the  worst 
catarrhal  inflammations  of  the  alimentary  canal,  and  greatly 
promotes  a  cure,  though  care  must  be  taken  that  the  patient  is 
properly  and  sufficiently  nourished.  To  persevere  long  with  a 
very  one-sided  or  deficient  diet  is  to  risk  impairing  nutrition  to 
a  serious  extent.  The  patient  should  be  weighed  from  time  to 
time  to  see  that  there  is  no  undue  loss  of  weight,  and  above 
all  you  should  keep  a  close  watch  upon  the  urine.  Until  you 
have  learned  to  judge  from  this  excretion  the  state  of  the 
metabolism — whether  or  not  the  nutrition  is  being  maintained 
at  the  proper  level — you  should  not  feel  yourselves  entirely 
competent  to  manage  complicated  cases  of  gastro-intestinal 
disease. 

The  Diet  in  Diarrhea  and  Constipation. — This  is  not  the 
place  to  discuss  at  length  the  diet  appropriate  to  either  diarrhea 
or  constipation,  and  they  are  fully  considered  in  subsequent 
lectures ;  but  it  may  be  said  in  brief  here  that,  while  in  diarrhea 
the  diet  should  be  as  non-irritating,  digestible,  and  nutritious 
as  possible — preferably  also  usually  in  rather  concentrated 
form — in  constipation,  even  in  the  atonic  variety,  it  will  not 
always  answer  to  have  it  too  bulky  or  irritating.  The  fruits 
and  cruder  vegetables  are  decidedly  contra-indicated  in  the 
former;  they  usually  favor  more  normal  evacuations  in  the 
latter,  and  are'  to  be  tried  hopefully  in  every  uncomplicated 
case ;  but  when  constipation  is  a  result  of,  or  complicated  with, 
a  catarrhal  process  in  any  portion  of  the  tract,  such  a  coarse, 
irritating   diet   will    nearly    always    disagree.       It    will   then 


DIET    IN    IRRITATIVE    CONDITIONS  223 

usually  either  increase  the  constipation  or  proVoke  frequent 
loose  stools  with  much  pain  and  flatulence — a  condition  worse 
than  the  original  disease.  One  way  in  which  an  irritating 
diet  will  sometimes  aggravate  is  by  provoking  an  excessive 
HCl  secretion  (hyperchlorhydria),  which  conduces  powerfully 
to  the  production  of  constipation.  This  is  most  likely  to 
result  from  an  excess  of  acid  fruits  in  the  dietary,  especially  in 
nervous,  excitable  persons  with  hyperassthetic  mucous  mem- 
branes. Spastic  constipation  has  not  yet  been  sufficiently 
studied  to  speak  too  positively  about  it.  In  this  form  of  the 
trouble,  which  yields  best  to  the  bromides  and  other  sedative 
remedies,  an  irritant  diet  would  a  priori  be  expected  to  dis- 
agree, and  yet  some  prominent  observers  have  reported  that 
it  often  seems  to  yield  to  a  diet  containing  much  cellulose,  as  is 
found  particularly  in  the  vegetables  and  fruits. 

Regarding  the  remaining  gastro-intestinal  diseases,  the  ptoses 
or  downward  displacements,  which  are  exceedingly  prevalent, 
and  the  malignant  growths  in,  or  adjacent  to,  the  digestive 
tube,  which  are  comparatively  infrequent,  the  diet  should  be 
adapted  to  whatever  associated  motor  or  secretory  derange- 
ment is  predominant,  though  it  must  always  be  as  little  irritat- 
ing .and  as  digestible  as  practicable,  and  also  as  nutritious  as 
can  be  digested,  even  with  the  aid  of  digestants  when  required. 
In  the  case  of  tumors  there  is  generally  in  the  stomach  deficient 
motility,  with  greatly  decreased  secretion  of  gastric  juice  and 
the  development  of  catarrhal  inflammation;  in  the  intestines, 
when  these  are  encroached  upon,  a  lowered  motility  and  secre- 
tion of  the  normal  juices,  with  usually  constipation  at  first, 
but  later  most  frequently  an  excessive  mucous  secretion  with 
diarrhea,  or  sometimes  constipation  alternating  with  diarrhea. 

Diet  can  do  little  for  the  exceedingly  prevalent  displace- 
ments of  the  abdominal  organs,  but  must  be  suited  carefully 
to  the  resulting  visceral  diseases. 

Proper  Cooking  and  Thorough  Mastication. — In  all  gastro- 
intestinal affections,  except  in  uncomplicated  atonic  constipa- 
tion, the  food  is  likely  to  agree  best  if  easily  digestible  and  not 


224  METHODS    OF    TREATMENT 

too  fermentable ;  also  if  finely  divided  and  properly  cooked, 
which  means,  in  the  case  of  eggs,  to  a  very  slight  extent  only, 
in  that  of  meat,  until  the  tougher  parts  are  softened,  but  never 
tyi  they  are  dried  up,  and  in  the  case  of  starch  foods  as 
thoroughly  as  possible,  until  the  hard  shell  of  cellulose  which 
surrounds  each  particle  of  starch  has  burst,  so  that  the  starch 
itself  can  be  acted  upon. 

A  point  of  the  greatest  importance,  too,  is  that  starch  food, 
particularly,  should  not  only  be  cooked  long  and  thoroughly, 
but  after  that  be  masticated  as  completely  as  possible.  This  is 
indispensable  for  many  reasons :  which,  though  they  have  been 
referred  to  at  some  length  in  a  previous  lecture,  cannot  be 
emphasized  too  strongly  and  therefore  are  here  briefly  sum- 
marized: (i)  It  tends  to  prevent  overeating;  (2)  it  insures  a 
more  perfect  comminution  of  the  food ;  ( 3  )  it  greatly  increases 
the  secretion  of  saliva,  which  at  the  same  time  converts  the 
starch  into  soluble  forms  (dextrine,  dextrose,  etc.),  and  then 
dissolves  it — /.  e.,  it  digests  it — and  it  cannot  otherwise  be 
digested  before  reaching  the  duodenum;  (4)  both  the  act  of 
chewing  and  the  alkaline  saliva,  thus  supplied  in  larger  amount 
to  the  stomach,  increase  the  secretion  of  the  gastric  juice;  and 
(5)  the  prolonged  movements  of  mastication  probably  also 
assist  reflexly  in  stimulating  the  secretion  of  the  pancreas  and 
intestinal  glands  as  well  as  the  peristaltic  movements  of  the 
gastric  and  intestinal  muscles. 

Dangers  in  Overrestriction  of  the  Diet. — One  more  general 
rule  should  be  insisted  upon  in  regard  to  the  dietetic  treatment 
of  indigestion  cases :  Do  not  restrict  the  diet  in  pure  nervous 
dyspepsia  when  there  is  no  considerable  derangement  of  either 
secretion  or  motility  in  the  digestive  organs ;  and  even  when 
these  are  demonstrably  involved  do  not  restrict  the  diet  too 
severely  or  in  too  sweeping  a  manner  unless  for  serious 
reasons  and  for  a  short  time.  While  a  scientifically  arranged 
diet  in  a  case  under  the  immediate  observation  of  an  expert 
physician  can  often  almost  alone  work  wonders  and  sometimes 
cure  magically  cases  that  had  resisted  other  treatment,  it  is 


DIET    IN    IRRITATIVE    CONDITIONS  225 

better  to  let  the  a\'erage  invalid  "  eat  everything  "  even,  than 
to  send  him  away  to  be  beyond  the  reach  of  his  physician  for 
weeks  or  months  at  a  time,  with  a  very  narrow,  meager 
dietary,  containing  mostly  articles  which  he  does  not  like  and 
cannot  eat  with  any  relish.  For  in  such  cases  the  patient,  in 
spite  of  our  science,  will  often  go  hungry  and  grow  thin  and 
weak.  IMoreover,  hyperchlorhydria  under  such  conditions 
will  sometimes  change  suddenly  into  hypochlorhydria,  and 
the  regimen  which  suited  perfectly  at  first  may  end  by  produc- 
ing a  dangerous  aggravation. 

Diet  in  the  Uratic  Diathesis. — Closely  related  to  disorders 
of  the  gastro-intestinal  tract  is  the  so-called  uric  acid  or  uratic 
diathesis,  and  in  the  treatment  of  this,  diet  is  all-important. 
Without  attempting  here  to  go  into  this  large  and  much- 
mooted  subject  fully,  I  may  be  permitted  briefly  to  express  a 
very  positive  conviction,  based  upon  a  considerable  experience, 
that  to  cure  the  condition,  besides  insuring  plenty  of  exercise, 
active  or  passive,  and  complete  elimination  through  all  the 
emunctories,  it  is  necessary  greatly  to  lessen  the  habitual 
ingestion  of  flesh  foods,  and  to  prohibit  altogether  the  eating 
of  the  glandular  portions  of  animals,  such  as  liver,  sweet- 
breads, calves'  brains,  kidneys,  etc.  In  the  worst  cases,  forbid 
also  the  use  of  meat  soups  or  meat  extracts,  as  well  as  coffee 
and  tea,  since  the  former  contain  a  very  large  proportion  of 
the  objectionable  uratic  products,  and  the  latter  contain  alka- 
loids almost  identical  with  the  xanthin  bases,  which  are  now 
believed  by  most  of  the  authorities  to  be  the  chief  offending 
substance  among  those  of  the  uric  acid  series. 

Sugar  also  often  has  to  be  restricted  in  such  cases,  for  the 
reason  that  it  is  not  only  very  fermentable,  but  so  much 
more  readily  oxidizable  than  the  proteids,  that  when  much  of 
it  is  taken  with  the  latter,  the  oxygenation  is  insufficient;  a 
portion  of  the  proteid  matter  ingested  is  left  unoxidized  with 
a  resulting  increase  of  the  injurious  products  of  suboxidation 
— to  wit :  the  xanthin  or  purin  bases,  together  with  other 
injurious  substances,  both  known  and  unknown. 


LECTURE  XIX 

SUGAR,    SPICES,    ETC.,   IN    GASTRO-INTES- 
TINAL   CASES 

The  Most  Difficult  Point  in  a  Difficult  Subject. — The  place 

of  sugar  in  the  diet  of  gastro-intestinal  cases  calls  for  special 
consideration.  It  is  one  of  the  most  difficult  points  in  the  whole 
subject  of  dietetics,  which  itself  comprises  perhaps  the  most 
difficult,  complicated,  and,  as  yet,  unsettled  part  of  practical 
medicine.  Sugar  is  essential  to  nutrition.  The  carbohydrate 
element  in  a  natural  dietary  needs  to  comprise  about  three- 
fifths  of  all  the  nutriment  taken,  and  must  be  converted  into 
dextrose,  a  form  of  sugar,  before  being  capable  of  assimilation 
in  the  body.  Its  oxidation  produces  most  of  the  heat  and 
force  which  are  essential  to  the  vital  processes.  Yet  when 
eaten  daily  with  the  heartier  meals  it  disagrees  with  most 
dyspeptics.  In  conditions  in  which  HCl  is  seci'feted  excessively 
by  the  gastric  glands,  sugar  has  been  demonstrated  to  have  the 
property  of  lessening  the  excessive  secretion.  JMoreover,  in 
these  hyperchlorhydric  cases  the  amylolytic  or  starch-convert- 
ing action  of  the  saliva  is  usually  much  interfered  with  by 
the  too  rapid  acidification  of  the  gastric  contents,  so  that  in 
such  cases,  especially,  I  have  often  observed  a  peculiar  sugar 
hunger,  indicating  that  the  system  is  not  getting  as  much  of 
this  food  element  as  it  requires.  In  so  far,  therefore,  sugar 
should  prove  useful  in  the  forms  of  indigestion  accompanied 
by  an  excess  of  HCl.  Another  point  of  importance  also  is  the 
fact  that  solutions  of  sugar  are  among  the  few  things  that  can 
be  absorbed  rapidly  from  the  stomach  itself  without  first  pass- 
ing through  the  pylorus  into  the  intestines,  thus  furnishing 

226 


SPICES    IN    GASTRO-INTESTINAL    CASES  227 

with  unusual  promptness  energy  to  the  tired  or  debihtated  body. 
Yet,  when  acting-  upon  the  suggestions  of  some  recent  writers, 
I  have  attempted  to  feed  sugar  freely  to  hyperchlorhydric 
patients  they,  while  usually  reporting  an  improved  feeling  of 
well-being  during  the  first  few  days  of  the  diet,  later  have 
almost  uniformly  shown  serious  embarrassment  as  the  result 
of  hepatic  derangement,  increased  flatulence  with  consequent 
insomnia,  and  sometimes  embarrassed  cardiac  action. 

How,  then,  can  we  solve  the  difficulty  and  furnish  more 
sugar  to  these  h3^perchlorhydric,  and  to  other  even  more 
debilitated,  patients  who  are  in  need  of  this  valuable  nutriment? 
It  has  been  suggested  by  some  writers  that  the  sugar  of  milk 
or  fruit  sugar  (levulose)  might  advantageously  be  substituted 
for  the  ordinary  cane  sugar  in  the  case  of  such  patients  as 
are  here  referred  to.  These  are  doubtless  somewhat  less 
fermentable  than  the  ordinary  commercial  sugar,  but  are  very 
expensive  and,  therefore,  not  very  practicable  for  use  as  foods. 
Besides,  even  though  less  fermentable  than  other  sugar,  they 
are  still  enough  so  to  produce  often  serious  distress  when  eaten 
at  all  freely,  in  the  usual  way,  along  with  other  food. 

An  Experiment  worth  Trying. — I  have  experimented  some- 
what in  this  line  with  results  which  are  at  least  interesting  and 
suggestive,  if  not  yet  conclusive.  I  have  noticed  that  the  first 
meal  or  two  in  which  sugar  has  been  largely  given  may  agree 
perfectly  well,  especially  if  no  strong  proteid  food,  such  as 
meat  or  eggs  or  indigestible  vegetables,  have  been  taken  at  the 
same  meal.  For  example,  a  patient,  who  had  found  previously 
that  to  top  off  a  dinner  with  ice  cream,  cake,  or  pudding  would 
invariably  produce  aggravated  flatulency,  has  reported  that 
when  an  occasional  light  luncheon  or  supper  has  been  eaten 
consisting  of  such  a  carbohydrate  combination  as  cake  and 
ice  cream  and  a  few  chocolate  caramels,  which  are  usually 
additionally  indigestible  for  most  dyspeptics  because  of 
the  large  proportion  of  oil  in  the  chocolate,  no  increased  flat- 
ulence or  other  unpleasant  results  have  followed.  If  these 
experiments  should  be  confirmed  by  a  more  extended  trial  of 


228  METHODS    OF    TREATMENT 

such  a  method  of  feeding,  it  may  be  possible  to  let  certain  of 
our  dyspeptic  patients  have,  say  twice  or  thrice  a  week,  one 
light  meal  of  the  kind  described — that  is,  made  up  chiefly  of 
^  sugar  combined  with  thoroughly  cooked  starch  in  a  form 
capable  of  being  chewed,  as  in  cake,  or  with  cream  or  milk  as 
in  ice  cream,  junket,  or  other  palatable  combination  of  these 
food  articles  or,  possibly,  in  the  milder  cases,  some  of  the 
nourishing  sweet  confections  compounded  of  sugar  and  nuts, 
though  these  last  would  be  much  more  risky.  Such  a  grateful 
and  valuable  addition  to  the  diet  of  many  dyspeptics,  even  at 
long  intervals,  would  greatly  lessen  the  sense  of  deprivation  of 
which  they  complain  when  denied  sweets  altogether  and  at 
the  same  time  help  much  to  increase  their  weight  and  nutrition. 
Moreover,  if  the  experiment  should  fail,  the  disagreement  of 
the  sweet  combination  taken  by  itself  would  convince  the 
patient  that  such  foods  must  be  avoided  altogether. 

Why  the  Sweets  often  Disagree  after  a  Dinner. — The 
reason  why  sugar  may  sometimes  be  made  to  agree  when  taken 
in  the  manner  above  indicated,  even  though  it  markedly  dis- 
agrees when  ingested  as  a  part  of  one  or  more  large  meals 
every  day,  is  not  far  to  seek.  ( i )  The  usual  sweet  dessert  taken 
after  dinner  is  nearly  always  simply  so  much  surplusage;  that 
is,  it  is  additional  food  taken  because  of  its  palate-tickling 
qualities  after  a  sufficiency  of  other  food  had  already  been 
taken,  and  often  after  the  stomach  had  been  greatly  overloaded 
with  the  substantial  of  the  meal.  (2)  Most  persons,  in  cities 
especially,  do  not  take  enough  physical  exercise  to  insure  the 
complete  oxidation  of  all  the  food  eaten  by  them,  and  it  is  a 
well-known  fact  that  sugar,  being  much  more  easily  oxidizable 
than  meat  and  vegetables,  will,,  when  taken  with  the  latter,  be 
oxidized  first,  thus  leaving  the  more  difficultly  oxidized  proteids 
to  remain  in  the  system  in  suboxidized  forms,  including 
especially  the  various  xanthin  or  purin  bases ;  and  these,  when 
in  excess,  exert  a  markedly  toxic  action  upon  various  im- 
portant structures  of  the  body.  (3)  The  liver  and  other 
organs  which  perform  the  function  of  converting  sugar  into 


SPICES    IN    GASTRO-INTESTINAL    CASES  229 

giycogen,  storing  it  up  and  again  distributing  it  to  the  system 
as  required,  are  readily  overtaxed  in  many  hyperchlorhydrics, 
so  that  a  moderate  meal  including  considerable  sugar  might 
be  well  tolerated  when  taken  two  or  three  times  a  week,  and 
the  patient  gain  largely  thereby;  while  sugar,  taken  once  or 
twice  a  day,  as  is  the  custom  of  many  Americans,  might  seri- 
ously derange  the  metabolism. 

It  ought,  however,  to  be  borne  in  mind  that  such  a  trial  of 
sweets  in  any  marked  case  of  dypepsia,  particularly  when  the 
liver  is  at  the  same  time  much  diseased  or  even  functionally 
impaired,  needs  to  be  made  with  great  caution.  The  patient 
in  every  instance  should  be  given  to  understand  clearly  that  it 
is  only  an  experiment  which  may  fail  with  the  result  of  tem- 
porarily aggravating  the  malady;  and  that  if  it  succeeds,  any 
attempt  to  repeat  the  experiment  daily,  especially  to  vary  it  by 
taking  the  sweets  along  with  hearty  meals,  would  be  likely  to 
prove  disastrous.  The  patients  who  should  respond  best  to 
this  method  of  feeding  sugar  are  those  who  usually  are  most 
in  need  of  it,  to  wit,  those  suffering  from  a  large  excess  of 
HCl  in  the  gastric  juice ;  but  it  will  not  agree  with  all  of  even 
these. 

THE   SPICES,   CONDIMENTS,   AND   BEVERAGES 

The  Spices,  etc..  Drugs,  not  Foods. — Under  the  head  of 
"  Prophylaxis,  Food  Requirements,  etc.,"  I  have  considered 
these  classes  of  articles  with  Sufficient  fullness  in  so  far  as 
regards  their  use  in  health.  I  told  you  that  they  are  drugs, 
and  not  foods  in  any  sense  of  the  latter  word ;  yet  like  other 
drugs  they  are  sometimes  of  use  temporarily  in  disease.  The 
results  of  experiments  have  been  contradictory  as  to  their 
effect  upon  secretion  at  first,  but  all  agree  that  in  the  end  they 
lower  it.  Lately  it  has  been  shown  that  some  of  the  spices 
by  their  primary  action  stimulate  the  motor  function  of  the 
stomach,  but  finally  depress  it,  just  as  depression  ultimately 
results  after  all  forms  of  stimulation.  Temporarily,  there- 
fore, the  spices  may  be  useful  as  an  addition  to  the  diets  of 


230  .  METHODS    OF    TREATMENT 

dyspeptics  having  a  poor  gastric  motility,  provided  they  are 
employed  merely  as  a  palliative  while  more  efficient  measures 
are  being  carried  out  with  a  view  to  a  definite  cure  of  the 
fault,  and  are  withdrawn  after  this  object  has  been  achieved. 

But  there  is  no  reason  to  believe  that  any  harm  can  follow 
such  a  slight  seasoning  of  foods  as  may  be  necessary  to  impart 
to  them  for  unspoiled  palates  an  agreeable  flavor,  and  salt 
being  a  necessary  constituent  of  the  body,  the  taste  for  it  is 
natural — one  to  be  satisfied. 

The  subject  of  the  choice  of  a  suitable  beverage  to  drink 
with  or  after  meals,  in  cases  of  gastro-intestinal  disease,  re- 
quires consideration. 

The  alcoholic  liquors  have  effects  which  make  them  un- 
desirable in  most  such  diseases — their  prolonged  use  in  all  of 
them.  Small  amounts  of  dilute  solutions  of  spirits  are  per- 
haps the  safest  when  a  stimulant  is  needed,  but  even  they  are 
contra-indicated  in  cases  of  excessive  secretion,  while  the  livers 
of  dyspeptics,  in  which  a  cirrhotic  process,  according  to  Boix,^ 
has  already  begun,  are  endangered  by  their  use  for  long 
periods,  tO'  say  nothing  of  their  cumulative  injurious  effect 
upon  hearts  and  arteries  in  which  degenerative  processes  have 
been  initiated. 

The  wines  and  fermented  liquors  have  injurious  properties 
of  their  own  dependent  upon  the  irritant  influence  of  the  acids 
which  they  always  contain,  in  addition  to  those  of  the  alcohol. 
Concerning  the  effect  of  the  latter  in  the  more  severe  gastric 
affections  many  leading  gastrologists  even  in  Germany  (where 
the  drinking  of  beer  is  almost  universal  among  all  classes) 
advise  against  them  as  a  general  rule.  Boas,  e.  g.,  says  :^ 
"  When  there  is  much  mucus  in  the  stomach  patients  must 
renounce  alcohol  and  tobacco." 

Professor  Riegel  of  Giessen,  after  summarizing  the  rather 

■>  "  The  Liver  of  Dyspeptics,"  by  Dr.  E.  Boix,  G.  P.  Putnam's  Sons,  New 
York,  1887. 

^  "  Diagnostik  u.  Therapie  d.  Magenkrankheiten,"  II  Theil,  Leipzig, 
1895,  p.  27. 


SPICES    IN    GASTRO-INTESTINAL    CASES  23 1 

contradictory  results  of  investigators  in  this  field,  is  ecjually 
emphatic,  saying:^  "In  general,  therefore,  we  may  say  that 
in  diseases  of  the  stomach  we  can  get  along  very  well  without 
alcohol.  In  all  conditions  in  which  the  stomach  is  irritable, 
as  in  ulcer,  acute  and  chronic  diseases  of  the  stomach  with 
increased  secretion  of  gastric  juice,  alcohol  is  to  be  con- 
demned." Then,  after  admitting  that  there  are  atonic  condi- 
tions in  which  a  glass  of  wine  may  seem  to  do  good,  Riegel 
goes  on  to  say  as  to  the  national  drink : 

"  Beer  is  hardly  to  be  recommended  in  diseases  of  the 
stomach.  The  relatively  large  quantity  of  fluid  taken  distends 
the  stomach  and  dilutes  the  gastric  juice,  so  that,  for  this 
reason  alone,  beer  is  not  a  proper  article  of  diet  for  many 
stomach  cases."  Then  after  referring  to  the  fermentation- 
exciting  action  of  beer  as  another  objection  to  it,  he  concedes  its 
harmlessness  in  small  doses  for  certain  classes  of  cases,  in- 
stancing here  "  simple  hyperacidity,"  which  the  sour  American 
beers  usually  aggravate  decidedly,  and  sums  up  the  matter 
thus : 

"  Beer  is  contra-indicated  in  all  cases  afflicted  with  atony  of 
the  stomach  with  ectasia,  with  ulcer,  and  with  hypersecretion. 
All  strong  spirituous  liquors,- particularly  drinks  prepared  with 
spices,  are  to  be  forbidden  in  stomach  diseases.  Champagne, 
too,  must  be  considered  a  beverage  that  is  in  general  unsuited 
for  diseases  of  the  stomach.  It  ivill  he  seen  from  all  that  has 
been  said,  that  in  general  alcohol  should  be  stricken  from  the 
diet  list  of  a  sufferer  from  any  disease  of  the  stomach;  only 
III  very  rare  cases  zvill  its  administration  be  advantageous." 

Coffee  and  tea  in  this  country,  where  alcoholic  stimulants  are 
not  largely  used  at  meals,  are  the  most  universal  table 
beverages.  Though  very  much  less  has  been  written  and 
spoken  against  these  popular  accompaniments  of  our  food, 
quite  as  little  can  be  said  in  their  favor  on  scientific  grounds ; 
they  are  capable  of  doing  nearly  as  much  harm  in  gastro- 

^  Nothnagel's  "  Practice,  Diseases  of  the  Stomach,"  Philadelphia,  Saun- 
ders &  Co.,  1903,  p.  219. 


232  METHODS    OF    TREATMENT 

intestinal  affections  when  used  at  all  freely,  and  especially  if 
taken  strong. 

Riegel  ^  considers  tea  safer  than  coft'ee  for  dyspeptics,  yet 
my  earliest  recollections  of  medical  practice  include  experi- 
ences with  indigestion  cases  in  Dr.  R.  G.  Curtin's  dispensary 
service  at  the  University  Hospital  in  Philadelphia,  when  that 
clever  clinician  was  accustomed  often  to  make  an  offhand 
diagnosis  of  "  tea  dyspepsia  "  in  servant  girls  the  moment  they 
entered  the  room,  from  a  certain  peculiar,  anxious,  drawn  ex- 
pression of  the  face. 

Schultz,  in  a  series  of  experiments  reported  ni  the  Zeifschrift 
fur  physiologische  Chemie  a  number  of  years  ago,"  found : 

1.  Under  the  conditions  of  the  experiment  94  per  cent,  of 
albuminous  digestion  when  neither  tea  nor  coffee  was  added 
to  the  digesting  mixture. 

2.  On  the  addition  of  tea  the  amount  of  digestion  was  only 
66  per  cent. 

3.  When  coffee  was  added  the  amount  of  digestion  was  66 
per  cent. 

In  the  stomach,  acting  through  the  nervous  system,  coffee 
and,  to  a  less  extent,  tea,  probably  stimulate  primarily,  but  sec- 
ondarily lower  the  digestion,  acting  like  all  stimulants  by  ex- 
hausting the  gastric  glands  prematurely. 

Stimulants  are  no  more  nor  less  than  drugs  in  spite  of  the 
fondness  of  many  of  us  for  word-juggling  concerning  them, 
and  drugs,  however  useful  now  and  then  for  short  periods 
under  medical  direction,  are  not  advisable  as  constant  and  per- 
petual additions  to  the  diet  of  any  sick  persons,  even  though 
they  may  be  tolerated  for  considerable  periods  by  well  persons. 

Water,  Milk,  etc — Water  is  the  basis  of  all  beverages  and 

constitutes  90  to  95  per  cent,  of  most  of  them.     If  it  must  be 

flavored  let  it  be  with  something  as  little  medicinal  as  possible, 

such  as  the  burnt  grains  of  some  one  of  the  cereals  or  in 

certain  cases  a  very  small  amount  of  lemon  juice,  or  good 

fresh  milk. 

^ Ibid.,  p.  221. 

2 "Eating  and  Drinking,"  by  Albert  H.  Hoy,   M.  D.,  p.  193. 


SPICES    IN    GASTRO-INTESTINAL    CASES  233 

Milk  itself,  however,  does  not  by  any  means  suit  all  dyspep- 
tics, being  very  liable  to  ferment  in  some  stomachs  and  intes- 
tines with  the  production  of  irritating  organic  acids,  gases, 
etc.,  besides  having  a  tendency  to  constipate  most  persons. 
Moreover  milk  is  a  decidedly  nourishing  food  which,  when 
ingested,  needs  to  be  taken  slowly,  so  that  it  can  be  digested, 
and  not  poured  down  hastily  as  beverages  are  likely  to  be. 
Every  adult  man  needs  five  to  six  pints  of  fluid  daily  to  do 
the  solvent  work  of  the  system,  and  the  more  pure  and  dilute 
the  form  in  which  most  of  it  is  taken,  the  better. 

The  required  amount  of  fluid  can  be  somewhat  less  in  the 
case  of  a  person  who  is  prevented  by  illness  from  actively  ex- 
ercising: and  for  gastro-intestinal  cases  it  will  make  much  dif- 
ference how  and  when  you  direct  it  to  be  taken.  In  marked 
hyperchlorhydria  it  may  be  drunk  rather  freely  during  and 
after  meals  to  dilute  the  overacid  gastric  juice,  and  this  prac- 
tice will  then  facilitate,  not  delay,  the  emptying  of  the  stomach. 
It  is  then  best  taken  rather  cool  or  cold,  but  not  ice  cold. 

In  constipation  a  liberal  drinking  of  water  between  meals, 
including  a  glass  of  cold  water  upon  arising,  will  assist  in  se- 
curing regular  evacuations  of  the  bowels. 

In  atonic  forms  of  stomach  trouble  there  should  be  little 
drinking  at  or  near  meals.  Most  of  the  fluid  required  should 
then  be  taken  between  meals,  and  much  less  in  the  aggregate 
tl  an  the  usual  amount  should  be  taken.  In  aggravated  or  ex- 
tensive gastric  dilatation  most  of  the  needed  fluid,  as  well  as 
some,  or  even  all,  of  the  food  and  medicine,  for  a  time  may 
need  to  be  given  per  rectum  to  avoid  overdistending  the 
stomach. 

In  nervous  forms  of  indigestion  not  dependent  upon  any  gas- 
tric or  intestinal  disease  the  patient's  inclinations  regarding 
water-drinking  may  be  allowed  to  guide,  except  that  excessive 
ice-water-drinking  should  be  forbidden. 


LECTURE  XX 

THE    AUTHOR'S    AND     OTHER    PROGRES- 
SIVE SERIES  OF  DIETS 

For  the  very  prevalent  cases  of  impaired  digestion,  espe- 
cially from  catarrhal  disease,  persistently  excessive  or  deficient 
secretion,  weak  motor  power,  gastric  ulcer,  etc.,  there  is  often 
much  advantage  in  having  at  hand  a  progressive  series  of  diets 
to  be  modified  as  each  case  may  require.  I  offer  the  following, 
v/hich  may  be  useful  to  you  if  not  prescribed  in  a  routine  way 
without  discrimination : 

Diet  No.  i. — Take  every  two  hours  from  a  wineglassful 
to  a  gobletful  of  peptonized  milk,  matzoon,  or  whey,  or  milk 
prepared  with  Eskay's  Food  according  to  directions ;  or  a 
teacupful  of  clam  broth,  chicken  broth,  beef  tea,  or  any 
meat  broth  slightly  seasoned  and  with  the  fat  all  skimmed 
off;  or  the  same  quantity  of  rice  water,  barley  water, 
toast  water,  gum-arabic  water  or  egg  water  may  be  given  as 
an  alternative  nutriment.  When  there  is  obstinate  vomiting, 
a  tablespoonful  of  any  of  the  above  may  be  given  every  fifteen 
minutes  till  the  stomach  has  been  settled ;  or  withhold  all  food 
by  the  mouth  and  feed  by  enemas  till  the  vomiting  has  been 
controlled. 

Diet  No.  2. — Take  every  two  to  three  hours  the  juice  from 
a  quarter  to  a  half-pound  of  lightly  broiled  lean  beef  expressed 
by  a  meat  press  or  lemon  squeezer ;  or  the  meat  may  be  chewed 
by  the  patient  and  the  juice  swallowed  while  the  fiber  is 
rejected.  Two  tablespoonfuls  of  Bovinine  or  an  equivalent 
amount  of  any  good  beef  extract  may  be  added  to  a  glass  in 

234 


PROGRESSIVE    SERIES    OF    DIETS  235 

which  the  whites  of  one  or  two  eggs  have  been  beaten  up, 
mixed  with  two  to  four  ounces  of  water  and  flavored  to  suit 
the  taste.  This  may  be  taken  every  two  to  three  hours  instead 
of  the  beef  juice  part  of  the  time,  as  an  ahernative  food,  in 
some  low  conditions ;  but  no  beef  extract  equals  fresh  beef 
juice  in  nutritive  value. 

Diet  No.  3. — Take  every  two  hours  one  to  two  goblets  of 
good  fresh  milk,  with  a  tablespoonful  of  limewater  or  a  pinch 
of  salt  in  it,  or  prepared  with  Eskay's  Food  according  to  direc- 
tions. It  should  be  sipped  slowly  and  may  be  preceded  by  the 
thorough  mastication  of  half  a  slice  of  stale  white  wheaten 
bread,  preferably  well  toasted,  or  the  same  quantity  of  un- 
sweetened zwieback,  but  neither  of  these  should  be  very  hard; 
or  by  two  or  three  Bent  &  Co.'s  water  crackers,  or  Educator 
crackers  may  be  taken  with  the  milk;  provided  great  care  be 
taken  to  see  that  the  crackers  are  fresh.  Thin  rice  or  barley 
gruel  may  in  certain  cases  be  mixed  with  the  milk  in  the 
proportion  of  one-third  gruel  to  two-thirds  milk.  No  other 
food  as  a  rule  should  be  taken  while  on  this  diet. 

Diet  No.  4. — At  any  of  the  three  usual  meals  a  few  of  the 
following  foods  may  be  selected : 

Broiled  lean  beefsteak,  lamb,  or  mutton  chop, — any  of  these 
scraped  so  as  to  obtain  the  pulp  and  juice,  avoiding  the  fiber 
and  fat;  finely  chopped  lean  beef  made  into  little  cakes  after 
the  removal  of  all  the  fat  and  gristle  and  then  broiled  over 
the  coals;  eggs  soft-boiled  or  poached;  stale  wheaten  bread 
(the  best  home-made  bread  is  preferable),  which  may  be 
lightly  toasted,  and  a  very  little  butter  may  be  eaten  on  it; 
good  fresh  gluten  wafers ;  zwieback,  unsweetened ;  a  little 
finely  ground  spinach  or  string  beans  well  cooked,  baked  or 
mashed  white  potatoes,  or  finely  ground  boiled  spinach. 

At  the  end  of  each  meal  a  cup  of  hot  water,  an  infusion 
of  cocoa  shells,  or  of  any  good  cereal  preparation  intended  to 
imitate  the  flavor  of  coffee. 


236  METHODS    OF    TREATMENT 

If  hungry  at  1 1  a.  m.  or  at  4  p.  m.,  take  one  or  two  raw  eggs 
well  beaten  and  mixed  with  water,  with  the  addition  of  beef 
extract  if  desired ;  or  instead,  stale  bread  and  butter  or  toast 
or  zwieback  may  be  taken  with  a  glass  of  hot  water  flavored, 
in  any  way  preferred. 

Except  in  the  cases  in  which  the  proper  tests  have  shown 
weak  motor  power  in  the  stomach  walls,  the  patient  may  drink 
freely,  though  not  more  than  a  single  gobletful  at  a  time,  of 
Poland  Spring,  Bethesda,  Clysmic,  Buffalo  Lithia  or  Apollinaris 
water,  or  any  good  pure  water  as  little  impregnated  with 
mineral  ingredients  as  possible,  but  not  any  of  the  stronger 
alkaline  waters  unless  especially  prescribed  by  the  physician. 
Rain  water  or  any  pure  soft  water  will  answer  the  purpose 
well,  if  boiled  to  destroy  all  germs  and  afterward  cooled  down 
and  recharged  with  air  to  give  it  life  by  shaking  it  a  few 
minutes  in  a  bottle  which  is  not  entirely  filled. 

Foods  and  Drinks  to  be  Avoided  while  on  Diet  No. 
4. — All  articles  not  especially  mentioned  as  permissible,  and 
particularly  all  foods  made  or  served  with  sugar,  shellfish, 
fried  things,  mufiins,  fresh  or  hot  rolls,  soda  biscuits,  flannel 
cakes,  etc. ;  bread  not  at  least  one  day  old ;  fruits ;  vegetables 
except  as  above  mentioned ;  nuts,  raisins,  candies,  pastries, 
ices,  cakes,  puddings,  twice-cooked  or  warmed-over  meats, 
cheese  as  a  rule  to  which  there  are  exceptions,  sausages  and 
scrapple  as  well  as  pickles  and  other  very  sour  things,  and  all 
hot  or  sharp  condiments,  spices,  etc.,  and  alcoholic  beverages 
except  as  specially  permitted.  Vichy  and  the  other  strong 
alkaline  waters  should  be  avoided,  except  when  prescribed  for 
hyperacidity  as  shown  by  a  chemical  analysis  of  the  stomach 
contents. 

Diet  No.  5. — Selection  may  be  made  from  any  articles  in 
the  previous  lists  and  from  any  in  this  table.  None  of  these 
foods  should  be  made  or  served  with  sugar  with  the  special 
exceptions  mentioned. 

Soups. — Any  plain,  simple  soup  not  too  rich  or  greasy. 


PROGRESSIVE  SERIES  OF  DIETS  2.';i^'J 

Fish. — Raw  oysters  in  their  season,  but  no  other  shellfish; 
any  other  kind  of  edible  fish  properly  cooked  except  eel,  salmon, 
herring,  and  salted  mackerel,  which  are  exceptionally  oily ;  and 
shad  should  be  eaten  sparingly  if  at  all. 

Meats. — Very  tender,  broiled,  lean  beefsteak,  lamb  chop, 
venison,  antelope  meat,  hare  or  rabbit,  chicken,  scjuab,  cjuail  or 
any  edible  bird  except  duck  or  goose ;  also  in  moderation,  ham 
well  boiled  and  afterward  baked;  broiled  or  stewed  sweet- 
breads, except  in  case  of  lith^emics ;  any  of  the  following  roasts, 
if  the  fat  and  gristle  are  carefully  rejected :  beef,  lamb,  mutton, 
chicken,  and  sparingly  of  turkey,  but  not  the  dressing  of  any 
roast  fowl  or  meat. 

Eggs. — In  all  forms  except  fried;  omelets,  if  baked  and  not 
fried;  eggs  in  baked  custards  and  light  puddings,  if  not  pre- 
pared with  sugar. 

Farinaceous. — Wheaten  bread  at  least  one  day  old,  and 
better  two  days  old;  toast  or  unsweetened  zwieback;  gluten 
wafers,  plain  water  crackers,  or  saltines,  or  Bent  &  Co.'s,  or 
Educator  crackers,  or  Uneeda  Biscuits.  These  forms  of 
bakery  products  are  very  liable  to  become  stale  before  sold, 
and  then  may  produce  much  flatulence.  Good  bread  a  day  or 
two  old  often  agrees  better;  corn  bread  made  without  sugar 
and  with  only  the  smallest  amount  of  shortening,  best  in  the 
form  of  the  Southern  hoe-cake  or  pone.  Any  of  these  breads 
may  be  lightly  buttered.  All  the  mushes  (which  are  usually 
swallowed  without  chewing  or  admixture  of  the  saliva)  are 
purposely  omitted  from  this  list;  but  small  portions  of  the 
thoroughly  dextrinized  breakfast  foods,  such  as  Force,  Grape 
Nuts,  and  Shredded  Wheat  Biscuits,  may  agree  well  when 
eaten  dry  and  even  when  taken  with  milk  (less  certainly  with 
cream)  are  much  better  tolerated  by  dyspeptics  than  oatmeal, 
cracked  wheat,  etc.  Boiled  rice  also  is  one  of  the  most  di- 
gestible of  the  cereals.     Rice  biscuits  are  still  better. 

Vegetables. — White  potatoes,  baked  in  their  skins  or  boiled 
and  mashed  with  milk  instead  of  butter;  baked  scjuash,  stewed 
celery ;  finely  ground  spinach ;  boiled  and  finely  mashed  car- 


238  METHODS    OF    TREATMENT 

rots  or  parsnips,  but  not  cooked  with  butter;  string  beans; 
young  and  very  tender  peas;  and,  merely  as  a  relish,  a  leaf  or 
^  two  of  lettuce  or  small  piece  of  uncooked  celery,  -served  with 
salt,  but  no  vinegar.     Also  any  vegetable  puree. 

Dessert. — A  sweet  orange,  a  baked  sweet  apple,  or  a  few 
white  grapes,  and  occasionally,  when  found  to  agree,  after 
cautious  trial,  a  fully  ripe  peach  or  pear;  also  sparingly  of 
stewed  fruits,  if  but  slightly  sweetened;  after  a  luncheon  or 
very  light  dinner,  one  tgg  made  into  a  baked  custard  with  milk, 
but  without  sugar.  If  flavored  with  vanilla,  lemon,  or  sherry, 
this  makes  a  delicious  dessert.  Also  curds  and  whey  without 
sugar;  very  sparingly  of  Iceland  moss  jelly  or  of  guava  or 
other  fruit  jelly;  a  small  portion  of  malted  milk  or  of  Hor- 
lick's  or  Mellin's  Food  served  with  fresh  cream;  but  these 
jellies  and  malted  foods  are  all  too  sweet  to  agree  with  many 
doubtful  stomachs,  especially  at  the  end  of  a  hearty  meal. 

Drinks. — Any  of  those  mentioned  in  No.  4,  or  a  glass  of 
Apollinaris,  Poland,  Bethesda,  Clysmic,  or  Buffalo  Lithia 
water  may  be  taken  at  the  end  of  the  meal;  and  also  one 
cup  of  chocolate  or  cocoa  if  taken  without  sugar,  or  very 
slightly  sweetened.  Water  may  be  drunk  freely  between  meals, 
except  in  the  cases  of  dilated  stomachs,  or  of  those  in  which 
the  motility  or  propulsive  power  has  been  found  deficient. 

Avoid  while  on  Diet  No.  5. — All  foods  or  drinks  not 
allowed  on  the  above  or  previous  lists.  Nuts,  raisins,  candies, 
shellfish,  pastry,  tarts,  rich  cakes  or  puddings,  or  other  des- 
serts, except  those  above  named  as  permissible,  raw  fruit  and 
vegetables,  except  as  above  allowed,  twice-cooked  or  warmed- 
over  meats,  cheese,  sausage,  and  scrapple,  vinegar,  sharp  or  hot 
sauces  and  condiments,  alcoholic  drinks,  strong  tea  or  coffee, 
and  sweetened  chocolate  or  cocoa,  as  a  rule,  to  which  there  may 
be  exceptions.  . 

Diet  No.  6. — May  take  in  addition  to  the  articles  mentioned 
-in  the  previous  lists: 


PROGRESSIVE    SERIES    OF    DIETS  239 

Soups. — Small  quantity  of  any  kind  not  too  rich  or  greasy. 

Fish. — Oysters  in  their  season  in  any  form  except  fried; 
no  other  shellfish,  but  any  of  the  other  edible  kinds  not 
fried. 

Meats. — Any  kind  of  cooked  meats  other  than  those  fried 
except  corned  beef,  salt  pork,  very  young  veal,  and  "  high  " 
game.  Duck,  goose,  and  turkey  should  be  eaten  spar- 
ingly, if  at  all,  by  persons  whose  digestion  is  doubtful,  and  the 
dressing  should  be  avoided  by  them  entirely.  Boiled  meats  are 
far  less  digestible  than  those  roasted  or  broiled,  as  well  as  less 
nutritious. 

Eggs. — In  any  form  except  fried  hard  or  combined  with 
sugar  in  rich  desserts. 

Grains  or  Cereal  Foods. — The  drier  forms,  such  as  stale 
bread,  toast,  and  crackers,  which  require  tO'  be  chewed,  are 
always  best ;  also  corn  bread,  rye  bread,  brown  wheaten  bread, 
and  rolls ;  but  a  moderate  amount  of  the  mushes  may  be  taken 
by  patients  whose  intestinal  digestion  has  been  restored  nearly 
to  the  normal.  The  best  of  them  are  Force,  Grape  Nuts, 
Shredded  Wheat  Biscuits,  Wheatena,  rice  flakes,  maize  flakes, 
thoroughly  boiled  rice,  the  finest  grades  of  cracked  wheat,  if 
cooked  overnight  in  a  double  kettle,  and  the  finest  well-bolted 
kinds  of  oatmeal  cooked  in  the  same  way.  They  should  be 
eaten  with  a  small  amount  of  fresh  cream  or  milk  and  mixed 
well  with  the  saliva.  Butter  may  be  taken  with  the  bread, 
except  at  dinner,  when  it  is  better  omitted. 

Vegetables. — Any  of  the  following,  well  cooked :  aspara- 
gus, beets,  Brussels  sprouts,  beans  in  puree,  or  very  thoroughly 
boiled  and  afterward  baked  till  brown;  cauliflower,  carrots, 
celery,  dandelion,  egg-plant,  mushrooms,  onions,  parsnips,  ten- 
der young  peas,  parsley,  potatoes,  not  fried  unless  in  the  form 
of  Saratoga  chips  shaved  very  thin,  pumpkins,  spinach,  string 
beans,  summer  squash,  sweet  corn  (if  young  and  very  tender), 
tomatoes,  turnips,  turnip  tops,  and  vegetable  oysters. 

The  following  uncooked  vegetables  may  be  partaken  of  spar- 
ingly, merely  as  a  relish,  since  they  are  difficult  of  digestion 


240  METHODS    OF    TREATMENT 

for  many  persons,  and  have  small  food  value:  lettuce,  olives, 
raw  celery,  and  cole  slaw. 

Dessert. — Oranges,  baked  apples,  ripe  peaches,  pears,  grapes. 
Bananas,  melons,  light  simple  puddings,  custards,  sparingly  of 
jellies,  and  very  sparingly  indeed  of  nuts.  Ice  cream  and  water 
ice  are  borne  fairly  well  by  many  not  robust  stomachs,  if  taken 
as  part  of  a  light  lunch,  yet  often  disagree  when  taken  at  the 
end  of  a  dinner.  If  eaten  after  dinner,  it  should  be  very  slowly 
and  in  small  amounts. 

Drinks. — Cocoa  or  chocolate;  very  moderately  of  coffee  or 
tea  not  too  strong,  though  one  is  better  without  these  in  the 
long  run.  The  lighter  wines  may  be  taken  by  those  accus- 
tomed :o  them,  except  where  there  is  a  tendency  to  hyperacidity. 
The  malt  liquors  are  better  avoided  as  beverages  by  even  con- 
valescents from  gastro-intestinal  diseases.  In  subacidity,  when 
there  are  indications  for  a  stimulant  with  a  diastasic-  prepara- 
tion, a  good  liquid  malt  extract  in  wineglassful  doses  may  be 
allowed ;  but  not  as  a  rule  the  beers,  ales,  etc.,  in  the  usual 
amounts.  In  cases  where  a  stimulant  is  really  indicated,  a 
very  small  portion  of  whisky  in  water  is  often  safer. 

Avoid  while  on  Diet  No.  6. — Very  rich,  very  sweet  or 
complicated  dishes ;  articles  fried  in  fat ;  soda  biscuits  and  all 
hot  or  even  fresh  breads  as  a  general  rule ;  most  kinds  of  shell- 
fish, except  oysters  in  their  season ;  pastries,  ices  after  a  full 
meal ;  sausage,  scrapple,  and  warmed-over  meats ;  very  strong 
coft'ee  or  tea,  and  large  cjuantities  of  any  coffee  or  tea ;  alco- 
holic beverages,  except  under  the  conditions  and  restrictions 
above  mentioned.  The  sharper  condiments,  such  as  pepper, 
mustard,  and  the  hot  sauces  should  be  either  avoided  or  taken 
very  sparingly. 

Classes  of  Cases  for  which  the  Foregoing  Diet  Lists  are 
Indicated. — Nos.  i  and  2  are  suited  to  acute  and  subacute  gas- 
tritis or  cases  of  irritable  stomach  from  whatever  cause. 
Aided  by  appropriate  medicines  and  other  accessory  measures, 
such  a  regimen  should  be  speedily  effectual,  and  not  need,  as  a 
rule,  to  be  continued  beyond  a  few  days. 


PROGRESSIVE   SERIES    OF   DIETS  241 

The  articles  prescribed  in  No.  3  usually  agree  well  with  cases 
of  subacute  gastric  catarrh  and  with  certain  forms  of  chronic 
gastric  catarrh ;  also,  with  acute  nephritis  and  any  of  the  other 
conditions  for  which  a  milk  diet  may  be  indicated.  It  answers 
for  the  severest  cases  of  hyperchlorhydria  and  for  gastric  ulcer 
after  a  preliminary  period  of  rectal  feeding.  Out  of  the  first 
three  tables  can  be  formed  a  good  regimen  for  advanced  cases 
of  gastric  cancer,  but  for  many  such  cases  some  of  the  things 
in  No.  4  would  need  to  be  added. 

No.  4  is  adapted  to  a  large  proportion  of  the  cases  of  chronic 
catarrh  of  the  stomach  (gastritis  chronica)  of  pronounced 
type  in  the  stage  in  which  they  are  usually  first  seen  by  the 
specialist,  as  well  as  to  many  cases  of  chronic  intestinal 
catarrh. 

No.  5  is  intended  especially  for  the  same  classes  of  diseases 
when  somewhat  further  advanced  toward  a  cure.  Nos.  4  and 
5  may  be  suited  to  the  treatment  of  numerous  chronic  affections 
in  which  a  simple  and  easily  digestible  and  yet  highly  nutritious 
diet  is'  required. 

No.  6  is  too  liberal  to  be  entirely  safe  for  most  dyspeptics 
even  when  convalescent,  but  it  serves  the  very  useful  purpose 
of  encouraging  them  to  look  forward  to  it  as  comparatively  a 
feast  of  good  things  to  which  they  may  hope  to  attain  later  on, 
and  at  all  events  it  is  a  simpler  and  safer  diet  than  that  to 
which  most  of  them  are  accustomed,  and  than  that  to  which 
they  would  promptly  return  upon  being  pronounced  convales- 
cent, unless  peremptorily  limited  to  a  less  hamiful  one  by  their 
physician.  It  can  easily  be  cut  down  to  the  exact  needs  of 
any  particular  case.  It  can  be  modified  also  by  simply  striking 
out  unsuitable  articles  so  as  to  answer  for  diabetes,  obesity, 
lith?emia,  and  numerous  other  diseases. 

For  catarrhal  inflammations  involving  both  the  stomach  and 
intestines,  the  lists  i  to  4  may  be  employed,  the  more  restricted 
ones  for  acute  or  severe  cases,  and  No.  4,  or  even  No.  5,  for 
the  chronic  ones  and  those  progressing  toward  recovery. 
When  the  catarrhal  inflammation  is  confined  wholly  or  mainly 


242  METHODS    OF    TREATMENT 

to  the  intestinal  mucous  membrane,  the  gastric  juice  being 
active  and  the  stomach  in  good  condition,  the  dietetic  treatment 
by  lean  meat  and  hot  water  with  the  addition  of  stale  bread  or 
toast  and  a  few  relishes,  often  suits  remarkably  well  if  not 
persisted  in  too  long.  Such  a  plan  of  diet  can  easily  be  adapted 
from  No.  4  or  No.  5  by  striking  off  the  vegetables  and  other 
articles  not  recjuired.  Aberrations  from  the  normal  in  the 
amount  or  character  of  the  gastric  juice — whether  they  con- 
stitute hyperchlorhydria  or  hypochlorhydria,  hyperpepsia  or 
hypopepsia — demand  special  dietetic  treatment  which  can  be 
readily  met  by  modifications  or  combinations  of  these  tables. 

Special  diet  directions  for  gastric  ulcer,  hyperchlorhydria 
and  other  important  diseases  axe  given  further  on  under  their 
respective  heads. 

DIET    DIRECTIONS   OF   LEUBE   AND    PENZOLDT 

It  should  be  of  interest  to  you  to  know  how  leading  German 
clinicians  and  specialists  in  digestive  diseases  direct  their 
patients  as  to  diet.  Leube  instituted  a  series  of  experiments 
upon  persons  with  impaired  -digestion,  to  determine  the  length 
of  time  that  the  principal  food  substances  and  preparations  re- 
quired to  digest  and  pass  out  of  the  stomach  in  such  cases.  He 
constructed  diet  tables  for  gastric  ulcer  and  other  serious 
diseases  of  the  stomach  based  upon  such  experiments,  and  so 
arranged  as  to  progress  from  a  list  of  the  simplest  and  most 
easily  digested  articles  up  to  one  containing  numerous  decid- 
edly strong  and  nourishing  foods  which  require  more  time  and 
digestive  power.^  I  append  here,  in  the  form  summarized  by 
Riegel, 

LEUBE'S   DIET   SCHEME 

Diet  I. — If  the  digestion  is  very  much  reduced,  the  follow- 
ing articles  of  food  are  most  easily  digested ;  bouillon,  meat 
solutions,  milk,  raw  or  soft-boiled  or  poached  eggs. 

Diet   II. — Less  digestible   than   Diet   I   are  the   following 

'  Nothnagel's  "  Practice,  Dis.  of  the  Stomach,"  by  Franz  Riegel,  Pro- 
fessor, etc.,  Philadelphia,  1903. 


PROGRESSIVE   SERIES   OF   DIETS  243 

articles  of  food:  boiled  calves'  brain,  boiled  thymus,  l^oiled 
chicken  and  pigeon.  These  different  kinds  of  meat  are 
enumerated  in  the  order  of  their  digestibility.  Other  articles 
of  food  that  are  permissible  are  gruels,  and  in  the  evening  milk 
mushes  made  with  tapioca  and  white  of  egg.  The  majority 
of  patients  can  assimilate  boiled  calves'  feet  in  addition  to  the 
articles  of  meat  mentioned. 

Diet  III. — If  Diet  II  can  be  digested,  Diet  III  follows.  The 
increase  consists  in  adding  cooked  or  raw  beef  to  the  above 
diet  list.  Leube  mentions  the  following  method  of  preparing 
beefsteak,  and  claims  that  beef  cooked  in  this  way  is  very 
easily  digestible.  The  meat  should  be  allowed  to  lie  for  some 
time  and  scraped  with  a  dull  spoon ;  in  this  way  a  meat-pulp 
is  obtained  consisting  only  of  the  delicate  parts  of  the  muscle, 
and  containing  none  of  the  tough,  hard,  and  sinewy  portions. 
These  meat-scrapings  are  roasted  in  fresh  butter.  Raw  ham 
is  also  permissible  in  this  stage. 

In  addition  to  meat,  a  little  mashed  potato  may  be  given, 
some  white  bread  that  is  not  too  fresh,  and  possibly  small 
cjuantities  of  coffee  or  tea  v/ith  milk. 

Diet  IV. — Roast  chicken,  roast  pigeon,  venison,  partridge, 
roast  beef,  medium  to  raw  (particularly  cold),  veal  (from  the 
leg),  pickerel,  boiled  shad  (even  young  ones  are  hard  to  di- 
gest), macaroni,  bouillon  with  rice.  Small  quantities  of 
wine  to  be  taken  one  to  two  hours  before  eating;  gravies  are 
contra-indicated.  Young  and  finely  chopped  spinach  is  the  best 
vegetable ;  other  vegetables,  as  asparagus,  may  be  tried,  al- 
though Leube  considers  this  a  risky  procedure.  The  patients 
are  allowed  to  take  a  more  liberal  diet  after  this  fourth  diet, 
but  the  increase  should  be  very  gradual.  They  should  refrain 
from  eating  vegetables,  salads,  and  preserves,  and  fruits  for  a 
long  time.  The  first  of  these  articles  that  they  may  eat  is  a 
baked  apple. 

Penzoldt  afterward  repeated  Leube's  experiments  upon 
healthy  persons  and  improved  upon  the  latter's  diet  tables,  con- 
siderably enlarging  and  extending  them.     He  constructed  a 


244 


METHODS    OF    TREATMENT 


series  of  four  diet  lists  founded  upon  similar  data,  including  the 
time  each  kind  of  food  remained  in  the  normal  stomach,  and 
added  directions  as  to  how  each  article  should  be  cooked  and 
^aten,  as  well  as  the  cjuantity  to  be  taken  at  a  time.  Penzoldt's 
four  lists  are  designed  to  train  the  weakened  digestive  ap- 
paratus gradually  and  progressively  up  to  the  full  performance 
of  its  work.  Numerous  authors  have  republished  Penzoldt's 
diet  tables,  and  they  are  generally  accepted  as  constituting  a 
reliable  basis  upon  which  to  arrange  dietaries  for  the  more 
serious  cases  of  gastro-intestinal  disease,  though  of  course 
every  case  requires  special  study  and  its  own  appropriate  diet 
directions.     I  reproduce  here  in  full  the  Penzoldt  scheme : 

PENZOLDT'S   DIET  TABLES   FOR   GRADUAL   TRAINING  OF 
THE   DIGESTIVE   CAPACITY 


First  Diet  (about  Ten  Days) 

Largest 

Foods    or   Drinks 

Quantity 

at 
One  Time 

Preparation 

Character 

How  to  be  Taken 

Bouillon      .     . 

250  gm. 

X  liter. 

From  beef. 

Lean, very  little 
salted  or  not 
at  all. 

Slowly. 

Cow's  milk.     . 

250  gm. 

Well  boiled,  or 

Pure    milk,     or 

If    preferred, 

%  liter. 

s  t  er  i  1  iz  e  d 

]4,  lime-water 

with   a    little 

(Soxhlet's  ap- 

and %  milk. 

tea. 

paratus). 

Eggs.     .     .     . 

One    or 

Very  soft,   just 

Fresh. 

If   raw,   should 

t  w  0. 

warmed   or 
raw. 

be  stirred  in- 
to the  warm, 
not  boiling 
bouillon. 

Meat  solution — 

30-40  gm. 

Should    have 

Teaspoon  f u 1 

(Leube-Ros- 

only   a    faint 

doses   stirred 

enthal's)     . 

odor  of  bouil- 
lon. 

into  bouillon. 

Cakes     (Albert 

Six. 

Without  sugar. 

Not     softened, 

biscuits).    . 

but  should  be 
well  masti- 
cated and  in- 
salivated. 

Water    .     .     . 

%  liter. 

Ordinary     or 
natural   car- 
bonated, con- 
t  a  i  n  i  n  g     a 
sma  11   pe  r- 
centage     of 
carbonic  acid 
(Selters). 

Not  too  cold. 

PROGRESSIVE    SERIES    OF   DIETS 
Second  Diet  (about  Ten  Days) 


245 


Largest 

Foods  or  Drinks 

Quantity 

at 
One  Time 

Preparation 

Character 

How  to  be  Taken 

Calf's  brain     . 

100  gm. 

Boiled. 

Freed  from  all 
membran  e  s 
and  fiber. 

Preferably   in 
bouillon. 

Sweetbreads, 

100  gm. 

Boiled. 

As    the    above. 

Best    in    bouil- 

(thymus 

Should    be 

lon. 

gland) 

peeled     out 
carefully. 

Pigeons .     .     . 

One. 

Boiled. 

Only  if   young, 
without  skin, 
tendons,   and 
the  like. 

Same  as  above. 

Chickens     .     . 

One,   the 
^ize  of  a 
pigeon. 

Boiled. 

As    above    (no 
fatten  e  d 

chickens). 

Same  as  above. 

Raw  beef   .     . 

100  gm. 

Finely  chopped  From   the   fillet 

To    be    eaten 

or  scraped,'     (tenderloin). 

with    bis- 

with   a   little 

cuits. 

salt. 

Raw-beef    sau- 

100 gm. 

Without     addi- 

Smoked a  little. 

As  above. 

sage    .     .     . 

tions. 

Tapioca .     .     . 

30  gm. 

Boiled     to      a 
gruel   with 
milk. 

Third  Diet  (about  Eight  Days) 

Largest 

Foods  or  Drinks 

Quantity 

at 
One  Time 

Preparation 

Character 

How  to  be  Taken 

Pigeon   .     .     . 

One 

To    be    broiled 
with    a    little 
fresh  butter. 

Only    young 
birds  without 
skin,  etc. 

Without  sauce 

Chicken       .     . 

One 

As  above. 

As  above. 

As  above. 

Beefsteak  .     . 

100  gm. 

With  fresh  but- 
ter, quite  rare 
(English). 

From    the   ten- 
derloin,   well 
beaten. 

As  above. 

Ham  .... 

100  gm. 

Raw,    scraped 

Smoked  a  little 

With    white 

fine. 

without   the 

bread. 

bones. 

Milk    bread, 

50  gm. 

Baked  crisp. 

Stale  rolls,  etc.  To   be    well 

toast,  or  Frei- 

chewed    and 

berg  pretzels. 

insalivated. 

Potatoes     .     . 

50  gm. 

Mashed,    or 
forced 
through   a 
strainer. 
Boiled  in  salt 
water      and 
mashed. 

The    potatoes 
should    be 
m    e   a  1  y  , 

crumbling  on 
crushing. 

Cauliflower     . 

50  gm. 

Boiled    in    salt 
water  as  veg- 

Only the    flow- 
ers to  be  used. 

etables. 

24^  METHODS    OF    TREATMENT 

Fourth  Diet  (about  Eight  to  Fourteen  Days). 


Largest 

Foods  or  Drinks 

Quantity 

at 
One  Time 

Preparation 

Character 

How  to  be  Taken 

Venison      .     . 

ZOO  gm. 

Roast. 

From  the  back, 
hung    for    a 
time,  but  not 
gamy;    with- 
out  high   fla- 
vor. 

Partridge   .     . 

One. 

Roast    without 
bacon. 

Young   birds, 
without  skin, 
tendons,  feet, 
etc.,    after 
having   hung 
for  a  time. 

Roast  beef.     . 

loo  gm. 

Medium  to  rare 

From    well-fat- 
ted   cattle  ; 
pounded. 

Warm  or  cold. 

Fillet      .     .     . 

ICO  gm. 

Same  as  above. 

Same  as  above. 

Same  as  above. 

Veal  .... 

loo  gm. 

Roasted. 

Back  or  leg. 

Warm  or  cold. 

Pike 

Boiled    in    salt 

Perch-pike 
Carp              I    ■ 
Trout           J 

water    with- 

The bones  to  be 

In   the    fish 

lOO  gm. 

out  any  addi- 

removed. 

gravy. 

tions. 

Caviar    .     .     . 

50  gm. 

Raw. 

Russian  caviar, 
slightly    salt- 
ed. 

Soft,     without 

Asparagus .     , 

50  gm. 

Boiled. 

With   a   little 

the  hard  por- 

melted butter 

tions. 

Rice  .... 

50  gm. 

Mashed    and 
forced 
thro  ugh     a 
strainer. 

Soft       boiled 
rice. 

Likewise. 

Poached  eggs. 

Two 
eggs. 

With    a   little 
fresh    butter 
and  salt. 

O  m  e  1  e  t  t  e 

Two 

With    about   20 

Must  have  risen 

To  be  eaten  at 

souffle      .     . 

eggs. 

gm.  sugar. 

well . 

once. 

Stewed  fruit  . 

50  gm. 

From    fresh 
boiled   fruit, 
forced 
through     a 
sieve. 

To  be   free   of 
skins     and 
seeds. 

Red  wine    .     . 

100  gm 

Light,    pure 
Bordeaux,   or 
similar    red 

wine. 

Slightly 
warmed. 

It  is  noteworthy  that  Penzoldt  allows  no  alcoholic  stimulant 
until  after  the  expiration  of  twenty-eight  days  of  treatment 
and  then  only  about  three  ounces  of  a  light  red  wine.  The 
calves'  brain  and  sweetbread  which  he  includes  in  his  second 


PROGRESSIVE    SERIES    OF    DIETS  247 

dietary  are  digestible  enough,  but  in  the  hght  of  recent  knowl- 
edge unsnited  to  the  many  dyspeptics  who  are  also  lithsemic, 
on  account  of  the  large  content  of  the  alloxuric  bases  which 
all  such  glandular  parts  of  animals  contain.  His  prescription 
of  raw  sausage  at  the  same  early  stage  of  the  treatment  of  a 
serious  stomach  case  would  be  open  to  criticism  also  from  the 
point  of  view  of  most  American  authorities  upon  dietetics,  and 
the  raw  meat  liberally  allowed  in  two  of  the  lists  would  not 
readily  be  taken  by  many  American  patients,  even  if  their 
physicians  cared  to  let  them  risk  the  dangers  of  trichinae,  the 
bacilH  of  tuberculosis,  etc.  The  very  liberal  allowance  of 
meat,  including,  in  the  form  of  bouillon,  much  of  the  meat  ex- 
tractives which  contain  its  most  soluble  and  toxic  ingredients, 
would  not  suit  well  in  the  very  numerous  cases  of  indigestion 
in  elderly  persons,  complicated,  as  so  very  many  of  them  are, 
with  disease  of  the  kidneys,  heart,  and  arteries. 

Nevertheless  the  dietaries  will  afford  you  valuable  sugges- 
tions for  your  guidance  in  many  difficult  cases. 


LECTURE  XXI 

FEEDING  BY  OTHER  ROUTES  THAN  THE 

MOUTH 

It  happens  in  many  cases  that  for  considerable  periods  either 
no  food  or  insufficient  quantities  of  it  can  be  taken  by  the 
mouth.  In  round  ulcer  of  the  stomach,  recent  hemorrhage 
from  the  stomach  or  esophagus,  whatever  the  cause  may  have 
been,  and  in  corrosive  poisoning  in  the  upper  part  of  the 
alimentary  canal  anywhere,  most  authorities  now  advise  giving 
the  stomach  complete  rest  till  the  acute  condition  has  been 
relieved;  in  gastric  ulcer  from  one  to  three  weeks.  Food  is 
given  by  the  bowel  meanwhile,  and  after  such  a  period  the 
usual  method  of  taking  nourishment  per  os  is  gradually  re- 
sumed. In  severer  grades  of  gastrectasis  it  is  also  generally 
agreed  that  rectal  feeding  greatly  assists  the  cure.  In  the 
worst  case  of  this  kind  which  I  have  ever  seen,  the  patient  hav- 
ing been  reduced  almost  to  a  skeleton  by  the  prolonged  attempt 
to  nourish  exclusively  by  the  mouth  when  there  was  frequent 
vomiting  and  very  little  absorption.  I  had  not  only  all  food, 
but  also  the  medicines,  administered  per  rectum,  while  the 
stomach  was  washed  out  daily  and  the  viscus  afterward  treated 
by  the  induced  current  (faradic  electricity),  intragastrically. 
This  patient  made  a  good  recovery  and  is  now  in  fairly  robust 
health  eight  years  afterward.  In  cancer  of  the  esophagus  or 
of  the  cardia,  or  obstruction  of  either  of  these  from  any  cause, 
the  patient  should  be  fed  by  nutrient  enemas  until  the  operation 
of  gastrostomy  can  be  performed. 

The  Technique  of  Rectal  Alimentation. — Formerly  it  was 
considered  necessary  to  have  all  proteid  food  introduced  into  the 
bowel  previously  peptonized,  but  Ewald  first  demonstrated  that 

248 


FEEDING    BY    OTHER    ROUTES    THAN    THE    MOUTH  249 

the  rectum  and  colon  when  healthy  can  absorb  eggs,  glucose, 
starch,  etc.,  in  such  a  form  as  to  be  assimilated  and  furnish 
nutriment  to  the  system.  Evvald's  directions  for  the  prepara- 
tion of  such  an  enema  are  as  follows :  Beat  up  thoroughly  2  or  3 
eggs  with  a  tablespoonful  of  water.  Have  ready  beforehand 
a  20  per  cent,  solution  of  glucose  boiled  with  a  pinch  of  the 
best  flour  and  add  a  wineglassful  of  claret.  When  this  solu- 
tion has  cooled  enough  not  to  coagulate  the  eggs,  the  two  are 
gradually  stirred  together  and  should  not  make  in  all  more 
than  half  a  pint.  In  hospital  practice  3  to  5  eggs  are  beaten 
up  and  mixed  with  about  5  ounces  of  a  1 5  or  20  per  cent,  solu- 
tion of  glucose  for  the  same  purpose.  The  addition  of  15 
grains  of  table  salt  for  each  egg  has  been  found  by  him  and 
other  observers  to  increase  markedly  the  absorbability  of  such 
enemas.  The  latter  are  introduced  with  a  soft  rubber  rectal 
tube  several  times  a  day,  after  a  preliminary  washing  out  of  the 
bowel  with  a  warm  salt  solution,  and,  it  is  said,  can  be  continued 
for  a  long  time  in  most  cases  without  being  rejected.  My  own 
experience  has  been  that  usually,  by  the  end  of  a  month,  the 
rectum  is  likely  to  become  irritable  and  then  no  longer  to  retain 
the  injection.  Ewald  has  found  it  necessary  in  some  cases  to 
add  a  little  starch  in  order  to  make  the  solution  more  viscid 
and  to  overcome  irritability  of  the  bowel;  also  sometimes  a  few 
drops  of  tincture  of  opium. 

He  adds  some  further  directions  that  are  worth  your 
particular  attention,  since  care  as  to  such  important  details 
makes  often  all  the  difference  between  success  and  failure.  He 
has  the  patient  lie  in  the  dorsal  or  left  lateral  position  during 
the  introduction  of  the  enema,  though  I  have  had  better  success 
with  the  patients  lying  at  first  on  the  left  side  and  then  after 
half  an  hour  or  so  having  them  turn  and  lie  on  the  right  side 
with  the  hips  somewhat  raised  upon  a  cushion.  This,  I  fancy, 
helps  to  carry  the  enema  by  gravity  over  intO'  the  ascending 
colon  and  cecum,  where  it  does  not  provoke  efforts  at  expulsion, 
and  where  also  there  should  be  more  rapid  absorption  than 
from  the  lower  end  of  the  large  bowel.     Ewald  further  advises 


250  METHODS    OF    TREATMENT 

that  the  vessel  holding  the  liquid  be  placed  about  two  feet  above 
the  anal  orifice  of  the  patient  and  the  enema  be  allowed  to  pass 
in  very  slowdy.  Time  enough  should  be  given  after  the  cleans- 
,  ing  injection  to  let  all  the  fluid  return  before  the  nutrient  enema 
is  introduced,  otherwise  there  would  be  danger  of  its  coming 
away  again  immediately.  Most  authorities  advise  having  the 
cleansing  injections  administered  an  hour  before  the  nutritive 
enema ;  also  that  the  quantity  of  the  latter  should  not  exceed 
half  a  pint.  It  is  further  important  that  the  patient  should 
rest  recumbent  for  an  hour  after  each  nutritive  enema. 

Boas'  Formula  for  a  Nutrient  Enema. — Riegel  bears  per- 
sonal testimony  to  the  eft'ectiveness  of  the  follow^ing  prescrip- 
tion of  Boas :  Half  a  pint  of  milk,  yolks  of  2  eggs,  a  small 
quantity  of  salt,  a  tablespoonful  of  red  wine  and  a  tablespoon- 
ful  of  "  Kraftmehl,"  instead  of  which  special  brand  of  flour 
probably  any  good  wheat  flour  would  answer  as  well.  In  view 
of  the  fact  that  albumin  is  especially  recjuired  by  the  system 
and  that  the  whites  of  eggs  are  quite  as  easily  absorbed  as  the 
yolks,  I  usually  order  for  an  enema  2  raw  egg's  well  beaten  up 
and  added  to  about  half  a  pint  of  milk,  a  saltspoonful  of  salt, 
and  when  there  is  any  need  of  stimulation,  a  tablespoonful  of 
whisky  or  brandy.     Sometimes  sugar  or  glucose  is  also  added. 

But,  notwithstanding  that  undigested  food  may  be  fed  per 
rectum  for  weeks  at  a  time,  there  are  cases  in  which  the  nour- 
ishment needs  to  be  continued  in  this  way  for  much  longer 
periods  and  then  the  method  recommended  by  Leube  has  much 
to  be  said  in  its  favor.  It  consists  of  chopped  meat  and  fat 
mixed  with  pancreas  in  the  following  proportions :  Chopped 
beef,  150  to  300  grms. ;  finely  chopped  and  fat-free  pancreas 
(from  hog  or  cow),  50  to  100  grms.  When  fat  is  desired  to  be 
a  part  of  the  feeding,  25  to  50  grms.  of  this  may  be  added. 
Riegel  reports  that  in  several  of  his  cases  he  was  enabled  to 
keep  patients  alive  for  months  by  feeding  in  this  w^ay,  and  one 
patient  with  stricture  of  the  esophagus  was  nourished  for  ten 
months  by  this  means  exclusively.  Any  method  of  rectal  feed- 
ing which  will  accomplish  such  results  should  be  considered 


FEEDING    BY    OTHER    ROUTES    THAN    THE    MOUTH  2^1 

invaluable  and  resorted  to  in  serious  emergencies,  regardless  of 
the  trouble  involved  in  carrying  it  out. 

Rectal  alimentation  should  be  employed  as  an  auxiliary  to 
other  feeding  much  more  largely  than  it  now  is.  You  will 
find  it  useful  as  such  an  auxiliary  in  any  case  in  which,  on 
account  of  disease  in  the  stomach  which  prevents  a  complete 
and  satisfactory  nourishment  of  the  patient  by  the  mouth,  the 
nutrition  is  suffering.  Besides  the  desperate  classes  of  disease 
above  mentioned  in  which  this  method  is  resorted  to  for  the 
purpose  of  saving  life,  it  will  prove  helpful  in  hyperchlorhydria 
of  severe  type  with  low  peptonizing  power  in  spite  of  excessive 
HCl;  also  in  numerous  cases  of  hypochlorhydria,  and  still 
more  in  achylia  gastrica  when  the  digestive  power  of  the  stom- 
ach does  not  speedily  come  up  under  the  treatment  carried  out, 
you  might  wisely  administer  nutrient  enemas  in  addition  to 
such  an  amount  of  food  by  the  mouth  as  the  patient  can  be 
made  to  take  and  digest.  In  such  conditions  this  sort  of  sup- 
plemental feeding  promises  more  than  a  dependence  upon 
forced  feeding  by  the  mouth  exclusively,  especially  if  at  the 
same  time  by  the  help  of  stimulating  soups  or  broths,  as  well 
as  by  the  administration  of  the  appropriate  stomachic  medi- 
cines, the  digestive  power  and  the  amount  of  food  ingested 
have  been  increased  as  much  as  possible.  Forced  feeding  is 
likely  often  merely  to  overburden  an  unwilling,  because  weak, 
stomach,  while  moderate  feeding  in  such  cases,  supplemented 
by  nutrient  enemas,  should  bring  up  nutrition  faster. 

The  Injection  of  Food  Subcutaneously. — Emergencies  have 
arisen  which  compelled  a  resort  to  other  methods  of  feeding 
than  either  those  by  the  mouth  or  rectum.  When  any  of  the 
conditions  exist  that  preclude  the  taking  of  nourishment  by 
the  mouth  and  the  rectum,  or  any  part  of  the  colon  is  the  seat 
of  disease  acute  enough  to  prevent  the  retention  of  enemas, 
some  other  means  of  feeding  must  be  found  if  life  is  to  be 
maintained.  Under  such  circumstances  subcutaneous  feeding 
has  been  practiced  for  short  periods  with  the  result,  apparently, 
of  affording  some  sustenance.     Numerous  experiments  on  ani- 


252  METHODS    OF    TREATMENT 

mals  have  been  done  to  determine  how  snch  subcutaneous 
injections  of  certain  foods  could  be  borne  and  the  results  upon 
,  nutrition,  and  it  was  found  that  oil  especially  could  be  used 
in  this  way  to  some  advantage.  Other  substances,  as  diluted 
milk,  solutions  of  sugar,  albumin,  etc.,  have  been  injected  in 
this  way,  and  it  has  been  demonstrated  that  these  were  ab- 
sorbed without  any  local  or  general  reaction.  In  the  compara- 
tively few  attempts,  however,  in  which  subcutaneous  feeding 
has  been  practiced  upon  human  beings,  olive  oil  or  other  bland 
fats  have  been  employed,  and  while  they  seemed  to  be  pretty 
well  tolerated,  exact  experiments  are  wanting  to  show  to 
what  extent  the  food  thus  introduced  has  been  utilized  for  the 
purposes  of  the  economy. 

Thomas  B.  Keyes  ^  of  Chicago  believes  he  has  proved  that 
subcutaneous  injections  of  oil  increase  the  cell  activity  of  the 
body,  and  thus  prove  a  valuable  stimulant  to  nutrition,  espe- 
cially in  tuberculosis,  when  fats  taken  by  the  mouth  are  not 
well  digested  and  assimilated. 

Patients  who  were  in  danger  of  perishing  for  want  of  nour- 
ishment have  also  been  placed  in  baths  of  warm  milk  with  some 
apparent  gain  to  their  nutrition.  However,  the  fact  that  a 
person  in  fair  health  may  live  for  several  weeks  without  any 
food  at  all  makes  it  a  little  uncertain  whether,  in  some  or  all 
of  such  cases,  the  patients  were  not  really  being  sustained  by 
the  oxidation  of  their  own  tissues. 

^Canadian  Jour,  of  Med.  and  Surg.,  May,  1906. 


LECTURE   XXII 

METHODS    OF    TREATMENT    IN    GASTRO- 
INTESTINAL DISEASES 

When  you  are  called  to  a  case  and  have  made  the  diagnosis, 
the  most  important  thing  of  all  is  to  decide,  when  possible,  the 
origin  or  cause  of  the  disease.  In  probably  four-fifths  of  all 
gastric  affections,  as  in  most  other  disturbances  of  health, 
Nature  would  gradually  effect  a  restoration  to  the  normal  con- 
dition, provided  all  causes  of  abnormal  functioning  could  be 
radically  and  permanently  removed.  This  point  cannot  be 
impressed  and  emphasized  too  strongly.  Most  of  our  failures 
are  due  to  our  inability  either  to  discover  the  exact  cause  of 
the  disease  or  to  remove  it  when  found.  Manifestly,  when  the 
cause  is  in  large  part  a  bad  inheritance,  it  cannot  be  removed ; 
but  fortunately,  bad  inheritance  alone  is  rarely  responsible 
wholly  for  the  derangements  of  health  which  we  are  called 
upon  to  treat.  It  is  merely  a  predisposing  cause,  and  when  in 
spite  of  it  the  patient  can  be  induced  to  live  in  strict  accordance 
with  hygienic  requirements,  he  may  enjoy  a  good  measure  of 
health  notwithstanding.  Many  failures  in  treatment  occur  in 
cases  in  which  the  physician  has  made  a  correct  diagnosis,  but 
places  too  little  stress  in  his  directions  to  the  patient  upon  the 
importance  of  changing  radically  the  faulty  modes  of  living 
which  produced  the  disease,  and  too  much  upon  our  remedies, 
especially  drugs.  Unless  we  stop  the  leak,  however,  which  is 
draining  away  the  energies  of  the  patient,  we  shall  make  little 
permanent  progress  in  curing  him,  whether  we  rely  chiefly 
upon  hydrotherapy,  massage,  or  other  manual  treatments,  elec- 
tricity, vibratory  stimulation,  climatotherapy,  or  merely  upon 
the  most  skillfully  concocted  combinations  of  medicine.     For 


254  METHODS    OF    TREATMENT 

example,  if  the  patient  habitually  overtasks  his  brain  or  other 
part  of  his  nervous  system,  he  will  be  only  temporarily  relieved, 
not  cured,  by  strychnine,  phosphorus,  etc.,  and  would  gain 
equally  little  permanent  benefit  from  any  of  the  above  men- 
tioned mechanical  modes  of  treatment.  The  society  woman 
who  squeezes  and  drags  her  abdominal  viscera  out  of  place  by 
tight  corsets  and  heav}^  skirts  suspended  from  the  lower  abdo- 
men and  spends  most  of  her  evenings  up  to  a  late  hour  in  the 
polluted  atmosphere  of  crowded  assembly  rooms,  ending  with 
an  indigestible  supper  at  midnight,  will  never  be  cured  of  her 
neurasthenia,  nervous  dyspepsia,  or  gastroptosis  until  her  habits 
in  these  respects  have  all  been  brought  into  conformity  with  the 
common-sense  rules  of  hygiene.  Incidentally  it  may  be  said 
here,  too,  that  the  uterine  displacements  of  such  women  can 
never  be  successfully  overcome  and  their  pelvic  organs  main- 
tained in  their  normal  place  until  the  malpositions  of  the  ab- 
dominal viscera  above  have  been  corrected  and  the  causes  of 
them  have  been  removed  by  the  patient's  abandonment  of  the 
irrational  modes  of  dress,  as  well  as  the  development  by  suit- 
able exercises  of  their  abdominal  muscles. 

Again,  the  student  and  professional  man  who  attempt  to 
achieve  impossible  tasks  b^^  cutting  short  their  allowance  of 
sleep,  and  whipping  up  their  exhausted  energies  to  enable  them 
to  follow  so  reckless  a  method  of  work,  by  drinking  strong 
coffee  or  other  stimulant,  can  manifestly  not  hope  to  regain  a 
normal  tone  in  their  nervous  and  digestive  systems  until  they 
can  be  induced  to  apportion  their  hours  of  work,  recreation, 
and  sleep  more  wisely. 

It  should  be  still  more  manifest  that  the  sedentary  clerk  or 
gluttonous  man  of  leisure,  who  regularly  eats  twice  as  much 
food  as  the  amount  of  exercise  taken  by  him  enables  him  to 
oxidize,  cannot  possibly  recover  health  and  stay  well  by  the 
consumption  of  any  quantity  of  stomach  bitters  or  artificial 
digestants.  He  might  find  more  temporary  benefit  from  mas- 
sage or  hydrotherapy,  since  these  procedures  increase  oxidiza- 
tion, but  the  gain  would  last  only  so  long  as  the  treatment 


TREATMENT    IN    GASTRO-INTESTINAL    DISEASES  255 

should  be  continued.  Equally  impossible  is  it  to  cure  and  keep 
well  a  patient  who  bolts  his  food  without  mastication  and  insal- 
ivation,  and,  regardless  of  Nature's  requirements,  takes  daily 
into  his  stomach  twice  as  much  proteid  matter  as  he  does  carbo- 
hydrates and  fats,  instead  of  letting  them  form  about  one-tenth 
of  the  total,  as  is  the  normal  proportion. 

If,  therefore,  you  would  make  permanent  cures,  insist  as 
strenuously  as  possible  that  your  patients  shall  reform  their  un- 
hygienic modes  of  living — not  only  their  eating  and  drinking, 
but  also  their  neglect  to  take  exercise — and  that  they  shall 
breathe  an  abundance  of  fresh  outdoor  air  as  little  contam- 
inated by  the  poisonous  products  of  our  civilization  as  their 
means  and  opportunities  will  permit.  There  are  ways  enough 
in  which  the  health  is  damaged,  including  many  vices  and 
unhygienic  practices,  into  the  details  of  which  it  is  unnecessary 
to  enter  here.  Suffice  it  to  say  that  all  departures  from  the 
normal  in  the  way  of  living  must  be  cured — reformed  alto- 
gether— if  the  results  achieved  by  our  treatment  are  to  be  satis- 
factory and  permanent. 

Therapeutic  Methods. — Coming  now  to  the  various  thera- 
peutic methods  in  vogue,  I  must  ask  the  indulgence  of  strait- 
laced  critics,  if  there  still  remain  any  who  are  in  sympathy  with 
the  authorities  satirized  by  Moliere,  and  represented  by  him 
as  having  exacted  of  candidates  for  the  degree  of  Doctor  of 
^ledicine  an  oath  never  to  alter  the  practice  of  physic.  For 
myself,  I  have  always  gloried  especially  in  the  fact  that  the 
adherents  of  regular  medicine  are  broad  and  catholic,  being 
fettered  by  no  creed  limitations,  but  free  to  make  use  of  any 
remedy  or  therapeutic  measure  which  experience  has  shown,  or 
can  show,  to  have  value.  This  is  in  marked  contrast  with  the 
creeds  of  the  many  sects  and  pathies  which  build  pretentious 
therapeutic  structures  upon  the  slender  foundation  of  a  single 
dogma  or  some  one  narrow  idea.  Hence,  in  these  lectures  I  do 
not  hesitate  to  sanction  the  use  of  any  remedy  or  therapeutic 
measure,  whether,  like  cod-liver  oil,  its  value  was  originally 
'liscovered  by  ignorant  fishwn'ves,  or  expectancy  and  minute 


256  METHODS    OF    TREATMENT 

doses  of  drugs,  the  frequent  effectiveness  of  which  we  have 
learned  from  the  homeopaths ;  electricity  and  water  locally  ap- 
plied, the  usefulness  of  which  we  learned  from  former  electro- 
,  paths  and  hydropaths  so-called,  or  other  forms  of  mechanical, 
manual  and  vibratory  stimulation,  some  of  which  are  nowadays 
becoming  popular.  According  to  my  understanding  of  the 
doctrine  held  by  us  as  regular  scientific  physicians,  it  is  our 
duty  to  prove  all  things  and  hold  fast  to  that  which  is  good, 
quite  regardless  of  its  source  or  of  alleged  faults  in  those  who 
first  employed  it. 

It  is  a  hopeful  feature  of  our  present-day  therapeutics  that 
more  direct  and  manageable  modes  of  influencing  disease  than 
the  administration  of  drug  remedies  are  increasingly  employed. 
We  are  learning  that  stimulation  or  sedation  of  a  diseased 
organ  can  often  be  more  quickly,  certainly,  and  safely  effected 
through  the  application  of  heat  or  cold  by  water  or  otherwise, 
or  through  some  one  of  the  numerous  other  mechanical  forms 
of  treatment,  gymnastic  exercises,  etc.  These  methods  can  be 
so  used  as  either  to  affect  the  whole  system  or  to  limit  the 
action  to  some  one  or  more  parts  without  disturbing  to  any 
considerable  extent  the  remainder  of  the  body. 

It  is  much  more  convenient  and  often  more  economical  for 
the  patients  to  depend  upon  medicines,  except  in  so  far  as  a 
skillfully  arranged  diet  may  promote  the  cure,  and  in  many 
diseases,  as,  for  example,  the  least  stubborn  cases  of  hyperchlor- 
hydria,  chronic  inflammation  of  joints,  eczema,  etc.,  active 
medication  with  alkalies,  nerve  sedatives,  or  salicylates,  iodides, 
purgatives,  etc.,  will  often  do  the  work  quite  effectually;  but 
rarely  without  exerting  an  injurious  effect  upon  other  structures 
including  some  of  the  nerve  centers,  with  a  considerable  depres- 
sion of  the  vital  force  which  most  chronic  invalids  can  ill  afford 
to  sustain.  Certain  of  the  forms  of  electricity,  etc.,  on  the 
other  hand,  can  now  be  so  used  as  frequently  to  cure  these 
chronic  conditions  rapidly,  not  only  without  injury  to  any 
other  parts  or  any  lowering  of  the  general  system,  but,  on  the 
contrar}'-,  with  the  advantage  of  actually  improving  the  general 


TREATMENT    IN    GASTRO-INTESTINAL    DISEASES  25/ 

nerve  tone.  It  is  exactly  analogous  to  the  modern  treatment  of 
fevers  by  cold  baths,  which  act  by  strengthening  the  nerve 
centers,  instead  of  antipyretic  drugs  or  the  older-fashioned 
bleeding  and  tartar  emetic,  which,  indeed,  lowered  the  fever, 
but  at  the  same  time  lowered  the  patient. 

Yet  medicines  are  often  indispensable  to  the  cure  of  certain 
diseases  and  in  very  many  cases,  when  used  with  the  skill  and 
precision  which  are  possible  only  after  making  an  exact  diag- 
nosis, may  prove  most  valuable  auxiliaries  to  the  more  directly 
acting  mechanical  forms  of  treatment. 

But  whether  you  administer  medicines  or  apply  other  modes' 
of  therapy,  or  both  combined,  you  will  need  to  be  careful  that 
in  your  zeal  to  cure  the  patient  you  do  not  overdose  or  overdo 
in  any  way. 

Overdosing  and  Overdoing  in  Therapeutics. — There  can  be 
no  fixed  dose  of  an  active  medicine  any  more  than  a  uniform 
size  for  a  drink  of  whisky.  With  regard  to  the  latter,  some 
persons  would  be  intoxicated  by  a  tablespoonful,  while  for 
others  a  half-pint  tumblerful  would  merely  steady  their  nerves. 
It  is  the  same  with  cathartic  medicine ;  we  have  all  seen  patients 
whom  a  teaspoonful  of  castor  oil  would  purge,  and  when  such 
persons  get  the  usual  drug-store  dose  of  an  ounce,  harm  must 
necessarily  be  done.  So  with  all  the  energetic  remedies  of  the 
Pharmacopeia.  The  same  dose  of  any  of  them  is  likely  to  act 
very  differently  upon  different  persons,  and  what  would  be  a 
suitable  stimulating  dose  for  those  of  robust  constitution  might 
seriously  overstimulate  weaker  ones.  The  only  safe  rule, 
therefore,  in  prescribing  for  a  new  patient,  is  to  begin  with  a 
dose  somewhat  under  the  minimum,  and  gradually  increase  it 
as  found  necessary  to  produce  the  desired  effect.  Such  a  pre- 
caution is  scarcely  less  necessary  in  prescribing  a  new  remedy 
for  any  patient.  The  so-called  dosimetric  method  of  admin- 
istering minimum  doses  of  the  active  principles  of  drugs, 
and  repeating  them  at  short  intervals  until  the  required 
effect  has  been  obtained,  has  thus  a  real  advantage  in  addition 
to    the    claim    of    its    advocates    that    there    is    greater    cer- 


258  METHODS    OF    TREATMENT 

tainty  in  the  results  to  be  accomplished  by  the  alkaloids  as  com- 
pared with  the  Galenic  preparations  of  numerous  remedies.  It 
is  safer  than  ordering  a  maximum  dose  at  once  in  a  threatening 
■^ase  with  directions  to  repeat  the  same  at  definite  intervals, 
regardless  of  effects. 

What  is  true  of  medicines  is  equally  true  of  other  thera- 
peutic measures.  Even  diet  cures  are  often  sadly  overdone,  to 
the  great  injury  of  the  patient.  The  same  is  true  of  exercise, 
massage,  electricity,  etc.  Patients  differ  most  widely  in  their 
response  to  every  sort  of  remedial  agency,  mechanical  as  well  as 
medicinal,  and  what  is  sauce  for  the  goose  is  decidedly  not 
always  sauce  for  the  gander.  You  will  find  it  wisest  to  begin 
with  much  less  than  the  usual  dose  of  any  such  agency  and 
study  its  effect  upon  each  individual  patient. 

Young  physicians,  especially,  need  to  be  reminded  that  Na- 
ture unaided  makes  innumerable  cures,  and  that  a  very  little 
assistance  at  just  the  right  time  and  place  may  be  all-sufficient; 
also,  that  our  drugs  sometimes  harm  more  than  they  help. 
Even  the  Christian  Scientists,  faith  curists,  etc.,  occasionally 
produce  astonishing  results  merely  by  stopping  medicines 
which  we  had  pushed  too  long  or  too  vigorously.  While,  when 
we  know  our  therapeutics  and  have  studied  our  cases  well,  we 
.should  not  be  too  timid  and  may  often  gain  much  by  boldness 
in  applying  needed  remedies,  yet  the  German  motto,  ''  Nur 
nicht  schaden  " — "  Only  don't  do  any  harm  " — sometimes 
embodies  the  safest  rule. 


LECTURE  XXIII 

THE  REMEDIAL  VALUE  OF  ACTIVE  EX- 
ERCISE, INCLUDING  OUTDOOR  GAMES, 
GYMNASTICS,  ETC. 

Exercise  Indispensable. — A  good  muscular  development  and 
a  daily  use  of  the  muscles,  especially  of  the  trunk  muscles,  are 
of  the  utmost  advantage  as  aids  to  digestion.  Body  workers 
need  give  no  thought  to  this  subject,  but  those  engaged  in 
sedentary  occupations  must  perforce  do  so  if  they  would  con- 
tinue in  even  fair  health.  Sedentary  workers  with  impaired 
digestions  will  find  attention  to  this  matter  of  physical  exercise 
an  important  requirement.  Most  of  them,  by  rising  half  an 
hour  earlier  in  the  morning,  can  go  through  a  few  gymnastic 
movements  for  the  trunk  muscles  followed  by  a  cold  sponge 
bath,  with  great  advantage,  and  when  their  day's  work  is  done, 
unless  unduly  exhausted,  should  take  as  long  a  walk  or  as  much 
other  exercise  in  the  open  air  as  is  practicable  for  them.  But 
when  the  nerve  force  has  from  any  cause  been  largely  lowered 
and  a  condition  of  marked  neurasthenia  been  set  up,  you  would 
err  gravely  in  advising  them  to  increase  the  exhaustion  which 
their  daily  labor  itself  produces  by  going  through  any  gym- 
nastic or  other  exercise  in  addition.  Such  patients  often 
recover  soonest  with  the  help  of  a  complete  rest  cure  and  in 
any  case  should,  if  possible,  take  a  short  vacation  from  work, 
devoting  it  largely  to  rest  in  the  recumbent  position,  with  an 
abundance  of  nourishing  but  digestible  food.  Failing  this,  they 
should  at  least  so  arrange  their  work  as  to  secure  the  longest 
possible  hours  for  sleep  and  fritter  away  none  of  their  nervous 
energy  by  useless  dissipations  in  the  evenings.  This  is  a  most 
important    practical    point    which    cannot    be    impressed    too 

259 


26o 


METHODS    OF    TREATMENT 


strongly  upon  all  physicians  who  have  the  management  of  those 
complicated  cases  of  indigestion  which  are  mainly  dependent 
upon  neurasthenia  or  overtaxed  energies. 

It  is  highly  probable  that  a  proper  attention  to  diet  and  exer- 
cise would  prevent  the  development  of  nearly  all  the  cases  of 
gastro-intestinal  disease  not  dependent  upon  traumatism  or 
some  other  outside  agency.  The  forms  of  exercise  most  valu- 
able in  the  treatment  of  these  affections  are  such  as  increase  the 
tonicity  of  the  abdominal  muscles  and  the  different  muscular 
layers  of  the  viscera,  including  the  muscular  walls  of  the  stom- 
ach and  intestines  particularly. 

Various  Kinds  of  Exercise. — Rowing  is  doubtless  the  best 
outdoor  exercise  to  effect  this  purpose,  and  among  those  prac- 
ticable in  gymnasiums  or  indoors  elsewhere  are  the  various 
turning  movements,  the  rowing  machines,  exercises  with  pul- 
leys, and  the  various  other  exercises  designed  especially  for  the 
trunk  muscles,  such  as  raising  the  upper  half  of  the  body  from 
a  horizontal  nearly  to  a  sitting  position  repeatedly.  The 
swinging  of  Indian  clubs  and  dumbbells,  and  many  of  the 
resisted  movements  which  bring  into  action  especially  the 
abdominal  muscles,  are  also  useful.  In  addition  to  the  special 
advantages  to  be  derived  from  the  exercise  of  the  muscles 
above  mentioned,  a  neglect  of  which  is  answerable  for  so  much 
dyspepsia  and  constipation  among  professional  men  and 
women  and  others  leading  a  sedentary  life,  it  cannot  be  too 
strongly  emphasized  or  too  often  repeated  that  exercise  of 
the  muscles  generally  is  not  only  helpful  in  all  such  cases,  but 
essential  to  the  health  of  every  animal.  Our  bodies  are  so 
constituted  that  without  frecjuent  movements  of  numerous 
groups  of  muscles  the  vital  processes  languish  and  very  slug- 
gishly and  imperfectlv  perform  their  functions.  Muscular 
movements  increase  all  the  oxidation  processes  and  facilitate 
the  circulation  not  onh^  in  the  veins,  arteries,  and  arterioles,  but 
also  in  the  lymph  vessels.  Therefore,  after  a  proper  regulation 
of  the  diet,  the  first  step  in  the  treatment  of  a  dyspeptic,  pro- 
vided he  or  she  be  not  profoundly  neurasthenic  and  in  need  of 


REMEDIAL    VALUE    OF    ACTIVE    EXERCISE  261 

a  prolonged  period  of  rest  with  passive  exercises  (massage), 
electricity,  and  nutritious  feeding,  should  be  to  see  to  it  that 
enough  exercise  is  taken  to  insure  a  perfect  combustion,  through 
oxidation,  and  a  proper  assimilation,  of  the  food  eaten.  In 
selecting  the  kind  of  exercise  to  be  prescribed,  regard  must  be 
had,  of  course,  to  the  physical  condition  as  well  as  the  social 
position,  occupation,  and  tastes  of  the  patient.  Horseback  rid- 
ing would  be  the  best  suited  to  a  large  proportion  of  the 
patients  who  have  the  means  and  leisure  to  indulge  in  it,  par- 
ticularly since  it  offers  a  maximum  of  movement  to  most  of  the 
structures  of  the  body,  with  a  minimum  of  fatiguing  effort ;  and, 
moreover,  takes  the  patient  usually  into  the  country,  where  the 
air  is  pure  and  the  surroundings  enlivening.  But  we  cannot  pre- 
scribe this  form  of  exercise  for  the  wife  of  the  workingman, 
who  is  borne  down  by  the  anxieties  and  cares  of  a  large  family ; 
nor,  as  a  rule,  for  the  bookkeeper  or  stenographer,  who  must 
spend  ten  hours  daily  in  the  counting-room.  The  poor  tired-out 
mother  usually  needs  most  a  season  of  rest  from  her  monoto- 
nous round  of  duties,  a  remedy  rarely  practicable  for  her;  but 
all  these  victims  of  closely  confining  occupations  would  profit 
greatly  by  a  daily  walk,  even  though  it  should  be  only  in  the 
city  streets  or  open  scjuares,  and  would  also  gain  much  by 
sponging  their  bodies  every  morning  with  cold  witer,  followed 
by  vigorous  friction  with  a  coarse  towel,  and  then  devoting  ten 
minutes  to  light  gymnastic  exercises  desig-ned  to  strengthen  the 
abdominal  muscles.  At  the  very  least  they  could  several  times 
daily  take  breathing  exercises  in  front  of  an  open  window,  and 
this  would  fill  up  their  lungs  with  fresh  air  and  lend  additional 
vigor  to  the  oxidation  processes.  Instead  of  such  rational 
means  of  improving  their  physical  condition,  many  sedentary 
indoor  workers  spend  a  large  share  of  their  evenings  in 
crowded  theaters  or  other  assembly  rooms,  where  their  systems 
are  still  further  poisoned  by  an  atmosphere  contaminated  by 
illuminating  gas  and  the  emanations  and  exhalations  from 
thousands  of  other  human  beings  packed  in  nearly  always 
imperfectly  ventilated  halls. 


262  METHODS    OF    TREATMENT 

Special  Forms  of  Gymnastics  Recommended.— It  may  be  as 

well  to  describe  here  a  few  of  the  more  useful  of  the  special 
gymnastic  exercises  which  may  be  carried  out  in  any  well- 
jVentilated  room  as  well  as  in  a  regular  gymnasium,  or  best  of 
all,  when  practicable,  in  the  open  air,  as  upon  the  roof  of  a 
house  so  constructed  as  to  permit  of  a  roof  garden  upon  it, 
or  on  any  porch  or  piazza. 

These  include  the  special  room  gymnastics  which  I  have  long 
been  teaching  my  patients.  It  is,  of  course,  impossible  to  go  fully 
into  this  large  subject  here  with  the  small  space  at  my  com- 
mand ;  but  those  of  you  who  are  interested  in  physical  culture, 
as  all  of  you  should  be,  will  naturally  procure  special  books 
concerning  it.  You  should  instruct  the  patient  always  to  begin 
by  raising  one  or  more  of  the  windows  in  even  the  coldest 
weather,  as  there  is  comparatively  little  gain  to  be  derived  from 
filling  up  the  lungs  with  exhausted  and  polluted  air.  Premis- 
ing, then,  that  the  windows  are  open  and  the  patient's  body 
clothed  as  lightly  and  loosely  as  practicable,  let  him  begin  by 
taking  two  breathing  exercises,  which  are  carried  out  as 
follows : 

1.  Stand  erect,  facing  the  open  window  and  only  a  short 
distance  back  from  it,  with  the  hands  at  the  sides,  palms 
inward,  the  body  kept  perfectly  erect.  Raise  the  arms  directly 
outward  and  upward  until  they  are  both  horizontal  with  the 
palms  still  downward,  meanwhile  inflating  the  lungs  through 
the  nose  slowly  and  continuously.  Then  let  the  arms  fall  rap- 
idly to  the  sides,  meanwhile  exhaling  as  forcibly  as  possible 
so  as  to  completely  empty  the  air  cells  in  order  to  permit  of 
the  entrance  of  a  new  supply  of  pure  air.  Repeat  this  mjDve- 
ment  three  or  four  times  and  then, 

2.  Standing  with  the  hands  in  the  same  position  as  before, 
raise  the  arms  again  to  the  horizontal,  and  then  turning  the 
palms  forward  carry  the  arms  around  nearly  in  the  same  hori- 
zontal plane  until  the  hands  meet  in  front.  Continue  the  infla- 
tion of  the  lungs  during  the  whole  of  this  movement.  Then,  as 
before,  let  the  hands  suddenlv  fall  to  the  sides  while  the  lungs 


REMEDIAL    VALUE    OF    ACTIVE    EXERCISE 


263 


are  forcibly  emptied.      This  movement  can  also  be  repeated 
three  or  four,  or  even  more,  times  with  advantage. 

3.  Begin  now  the  gymnastic  movements  proper  by  support- 
ing the  body  with  the  hands  on  the  front  of  an  ordinary  chair 


Fig.  32. — Chair  exercise  for  arm  and  trunk  muscles. 


on  either  side,  while  the  body  is  extended  so  that  it  is  sup- 
ported wholly  upon  the  toes  and  upon  the  hands  resting  upon 
the  chair.  While  in  this  position  bend  the  arms  at  the  elbows 
and  swing  the  middle  part  of  the  body  as  far  down  as  possible 
and  then  bring  it  back  .to  the  original  position.     This  exercise 


Fig.  33. — Second  position  of  tlie  same. 

need  not  be  done  more  than  once  during  the  first  two  or  three 
periods  of  practice,  and  after  that  it  may  be  repeated  oftener 
up  to  three,  four,  or  even  five  times  in  persons  who  have  a 
fair  degree  of  strength  in  their  abdominal  and  back  muscles. 
(See  Figs.  32  and  33.)^ 
4.  Stand  erect,  with  the  feet  eight  to  ten  inches  apart,  and 

^  These  illustrations  have  been  taken  from  "  Hygiene  in  the  Treatment 
of  Dyspepsia,"  published  by  The  Brunswick  Pharmacal  Cq.  of  New  Bruns- 
wick, N.  J. 


264 


METHODS    OF    TREATMENT 


without  flexing  the  knees,  bend  the  body  forward,  with  the 
arms  extended  until  the  fingers  approach  as  near  to  the  floor 
-,  as  the  patient  can  get  them,  while  the  knees  are  kept  extended. 
In  following  this  movement,  the  bend  should  be  largely  at  the- 
hip  joints,  but  also  in  part  at  all  the  joints  of  the  spinal  column. 
Not  many  persons  can  reach  the  floor  at  first,  but  the  majority 


'\d^^\'  1 


Fig.  34, — Forward  and  backward  body-bending. 


can  after  a  little  practice.  This  exercise,  like  the  preceding 
one,  should  not  be  repeated  more  than  once  or  twice  at  the 
earlier  attempts,  but  with  increased  practice  may  finally  be  done 
half  a  dozen  times  during  each  exercise  period.     (See  Fig.  34.) 

5.  Immediately  after  finishing  Exercise  No.  4,  the  patient 
should  revolve  the  upper  half  of  the  body  upon  the  hips  as  a 
pivot,  bending  first  far  forward,  then  to  the  right,  then  back- 
ward, then  to  the  left  and  finally  forward  again  and  so  on 
around.  This  last  movement  is  not  difficult  and  can  be  done 
five  or  ten  times  at  once.  It  is  very  useful  in  stimulating  the 
peristaltic  action  in  the  intestines  and  in  strengthening  the 
abdominal  muscles. 

6.  Let  the  patient  sit  on  a  low  stool  and  revolve  as  in  the 


REMEDIAL    VALUE    OF    ACTIVE    EXERCISE 


265 


preceding  exercise.  By  reason  of  the  flexed  position  of  the 
thighs  this  produces  even  a  greater  stimulation  to  the  peri- 
staltic apparatus.     (See  Fig.  35.) 

7.  Let  the  patient  lie  down  upon  the  back  on  a  firm  level 
surface,  such  as  a  rug  upon  the  floor  or  on  a  straight  couch. 


Fig.  35. ^Rotary  movement  of  the  trunk  while  sitting. 


Then,  while  the  lower  half  of  the  body  remains  horizontal, 
slowly  raise  the  head  and  thorax  to  the  perpendicular.  Then 
as  gradually  return  to  the  horizontal  position,  not  letting  the 
upper  half  of  the  body  fall  back  quickly.  After  raising  the 
tipper  half  of  the  body  in  this  manner,  allow  that  part  to  remain 
horizontal  while  the  legs  are  slowly  raised  as  nearly  to  the 
perpendicular  as  possible  and  then  as  slowly  returned  to  their 
former  position.  Repeat  these  movements  each  two  or  three 
times  in  the  beginning,  but  later  they  may  be  gradually  in- 
creased to  twenty  or  thirty  times  at  each  exercise  period,  but 
never  until  fatigued. 

8.  Stand  erect  with  the  feet  eight  to  ten  inches  apart  and 
bend  the  knees  as  much  as  possible  until  the  buttocks  approach 


266 


METHODS    OF    TREATMENT 


closely  to  the  heels  in  the  squatting  position,  the  body  resting 
wholly  upon  the  toes.  Then  slowly  raise  the  body  again  to  the 
original  position.  Repeat  this  two  or  three  times  at  first  and 
later  five  to  ten  times. 

9.  A  very  useful  form  of  exercise  which  can  be  practiced 
while  standing  or  sitting  in  a  room,  or  even  when  walking  out 


Fig.  36. — Pulley  exercise  for  arm  and  trunk  muscles. 

of  doors,  is  the  alternate  contraction  and  relaxation  of  the 
diaphragm  and  abdominal  muscles,  producing  movements 
resembling  those  which  constitute  one  of  the  Oriental  dances 
first  introduced  into  this  country  at  the  time  of  the  Chicago 
Fair. 

10.  Exercises  with  pulleys  or  elastic  cords  as  shown  in  the 
accompanying  illustrations,  Figures  36  and  37.  The  apparatus 
for  pulleys  with  weights  are  cumbrous  and  somewhat  expen- 
sive, but  the  elastic  cords  with  pulley  attachments  are  quite 
inexpensive  and  can  be  obtained  of  any  dealer  in  athletic  goods. 
These  cords  can  be  so  used  as  to  strengthen  greatly  the  ab- 
dominal muscles.  Ijut  the  above-described  exercises,  3  to  9,  will 
effectithe  same  results. 

There  are  manv  other  exercises  which  might  be  described 
here,  but  the  above  will  suffice  if  carried  out  properly  and 


REMEDIAL    VALUE    OF    ACTIVE    EXERCISE 


267 


sufficiently  often.  They  are  those  best  adapted  to  the  develop- 
ment of  the  abdominal  and  trunk  muscles  generally,  whose 
functional  activity  is  indispensable  to  a  normal  performance  of 
the  digestive  functions.  They  should  not  be  depended  upon 
entirely,  since  other  exercises  for  the  development  of  the  arms, 


Fig.  37. — Same  with  low  attachment  of  the  pulleys. 

the  thoracic  muscles  or  other  trunk  muscles,  etc.,  are  almost 
equally  important ;  and  no  person  ought  to  be  content  with  the 
performance  of  indoor  exercise  exclusively,  however  good  or 
often  repeated.  Exercise  in  the  open  air  is  very  necessary  to 
the  restoration  and  maintenance  of  perfect  health,  and  those 
dyspeptics  who  possess  the  requisite  means  and  leisure  should 
row,  ride  horseback,  walk,  or  play  at  some  not  too  violent  out- 
door game  such  as  golf  or  croquet  for  an  hour  or  two  on  at 
least  every  pleasant  day  the  year  round.  The  stronger  patients 
may  safely  indulge  in  the  more  active  games  including  tennis, 
basket-ball,  bicycling,  etc. 


LECTURE    XXIV 

PASSIVE    EXERCISES,    INCLUDING  MAS- 
SAGE—THE   REST  TREATMENT 

There  are  numerous  methods  of  modifying  the  nutrition  of 
the  body  which  are  properly  classed  under  the  head  of  passive 
exercise.  Chief  among  these  are  massage  and  unresisted 
Swedish  movements.  Similar  movements  resisted  by  the 
patients  are  really  active  exercise  for  both  patient  and  operator. 
Riding  in  any  kind  of  conveyance  involves  a  constant  vibration 
which  is  more  or  less  stimulating — a  passive  form  of  exercise 
unless  the  patient  drives  a  spirited  team,  when  it  ma}^  become 
decidedly  active.  Riding  in  trolley  or  steam  cars  affords  thus 
a  kind  of  passive  exercise  of  which  persons  resident  in  the  sub- 
urbs of  cities  necessarily  take  a  certain  amount  daily.  Some 
observant  patients  who  travel  ten  to  twenty  miles  every  day 
in  this  way  have  reported  to  me  that  they  find  it  stimulat- 
ing or  tonic,  while  weaker  persons  experience  overstimulation 
and  fatigue  from  the  same  cause. 

The  kind  of  vibration  now  produced  by  special  machines, 
driven  usually  by  electric  motors  and  employed  for  the  local 
stimulation  of  various  parts  of  the  body,  comes  under  the  same 
category,  as  indeed  does  the  so-called  manual  therapy  as  well  in 
fact  as  the  various  electric  modalities.  But  these  are  discussed 
elsewhere  in  this  series  of  lectures,  under  their  respective 
heads. 

Massage  and  the  Swedish  movements  alone,  to  sav  nothing 
of  the  other  kinds  of  passive  exercise,  constitute  a  very  large 
subject,  well  worthy  of  your  study — one  concerning  which 
many  books  have  been  written  without  exhausting  it.  Mas- 
sage and  the  kindred  passive  movements    afTord  a  most  valu- 

268 


PASSIVE    EXERCISES^    INCLUDING    MASSAGE  269 

able  means  of  influencing  the  circulation  and  nutrition  of  all 
the  bodily  structures.  It  is  often  most  clumsily  done  by  in- 
competent manipulators  and  without  a  proper  and  intelligent 
supervision  by  the  physician.  In  gastric  and  intestinal  disease 
it  is  an  efficient  stimulant  to  both  the  secretory  and  motor 
functions  in  any  part  of  the  tract  when  properly  given ;  but  it 
may  be  even  skillfully  applied  with  the  result  of  producing 
harm  instead  of  good,  as  in  cases  of  excessive  secretion  of  HCl 
and  in  spastic  constipation,  in  the  latter  of  wdiich  there  are 
spasmodic  contractions  of  the  circular  muscles  of  the  intestines 
with  the  result  of  retarding  the  onward  passage  of  feces. 
Vigorous  massage  increases  the  previously  existing  hypersecre- 
tion of  the  gastric  juice  and  also  the  spasmodic  contractions 
above  mentioned.  Alassage  is  sometimes  too  vigorously  ap- 
plied also  over  sensitive  regions  in  the  spine  which  would  be 
benefited  by  very  slight  stimulation,  but  aggravated  by  the 
repeated  and  strong  irritation  of  daily  or  tri-weekly  forcible 
kneadings.  In  kneading  the  abdomen,  too,  much  harm  can 
easily  be  done  when  there  is  a  displaced  and  tender,  congested 
kidney,  as  well  as  in  various  acute  or  subacute  inflammations. 
In  brief,  if  all  physicians  were  better  acquainted  with  the 
extreme  value  of  properly  given  massage  in  suitable  cases 
and  with  the  possible  injuries  which  may  result  from  it  when 
improperly  applied,  this  method  of  treatment  would  be  much 
more  widely  and  advantageously  used  than  it  now  is.  Mas- 
sage can  only  be  taught  by  practical  demonstrations,  and  it 
would  therefore  be  quite  useless  to  give  here  any  extended 
account  of  the  various  manipulations  and  the  technique  of 
applying  them.  Some  time  ago  I  observed  carefully  a  series  of 
cases  in  w^hich  abdominal  massage  was  either  the  only  or  chief 
form  of  treatment.  These  vv^ere  mostly  cases  of  neurasthenia 
with  the  stomach  more  or  less  involved.  In  a  larger  number 
of  cases  under  treatment  by  massage  together  with  other 
therapeutic  measures,  the  functional  work  of  the  gastric  glands 
was  greatly  enhanced ;  but  the  difficulty  in  many  of  these  is  to 
determine  to  what  part  of  the  treatment  the  result  was  due. 


270  METHODS    OF    TREATMENT 

HCl  Increased  by  Massage. — In  the  following  cases  abdom- 
inal massage  was  the  main  dependence  in  the  way  of  treatment ; 
no  drugs  were  given  beyond  a  laxative,  as  required.  The  diet 
was  a  mixed  one,  from  which  sweet  things,  hot  or  fresh  bread, 
shellfish  and  other  highly  fermentable  articles  were  excluded: 

Case  I. — Chronic  gastric  catarrh  with  slight  intestinal 
catarrh  in  a  professional  man,  aged  forty-nine.  There  had 
formerly  been  an  excess  of  HCl,  but  under  treatment  this  had 
been  reduced  and  for  several  months  the  percentage  of  that 
acid  had  ranged  between  .040  and  .050. 

After  three  weeks  of  abdominal  massage,  twice  a  day — 
morning  and  night — following  the  drinking  of  a  glass  of 
water,  the  HCl  had  increased  to  .114.  No  drugs  had  been 
given  meanwhile,  except  small  laxative  doses  of  extract  of  cas- 
cara  at  bedtime. 

Case  11. — Neurasthenia  with  ansemia  and  chronic  gastritis. 
On  March  13,  1897,  the  proportion  of  free  HCl,  by  the 
Mintz  method,  was  found  to  be  .065 ;  total  acidity,  54.  With 
no  active  treatment  except  abdominal  massage,  meanwhile,  a 
test  on  April  15,  one  month  later,  showed  free  HCl  .091 ;  total 
acidity,  59. 

A  large  number  of  cases  have  occurred  in  my  practice  in 
which  a  total  absence  of  HCl,  pepsin,  and  the  rennet-ferment 
persisted  in  spite  of  both  massage  and  the  administration  of 
HCl  along  with  various  other  roborant  measures,  showing  the 
existence  probably  of  gastric  atrophy ;  but  in  other  cases  of 
chronic  gastric  catarrh  the  amount  of  free  HCl  was  finally 
restored  under  an  energetic  treatment  by  means  of  massage  and 
galvanism  together  with  the  administration  of  both  HCl  and 
pepsin  persevered  with  for  long  periods — in  one  instance  for 
most  of  the  time  during  a  period  of  five  or  six  months,  with 
lavage  employed  in  addition  during  a  part  of  the  time. 

Since  the  welfare  of  the  patient  has  always  seemed  to  me 
greatly  more  important  than  even  the  establishment  of  a 
possible  truth  in  medical  science,  I  have  never  depended  upon 
massage  alone  in  any  case  of  anacidity  or  achylia  gastrica,  but 
as  the  indications  for  supplying  the  deficient  pepsin  and  acid 


PASSIVE    EXERCISES^    INCLUDING    MASSAGE  2/1 

seemed  so  positive,  and  practical  advantages  derivable  there- 
from have  often  been  so  immediate  and  decided,  I  have 
generally  administered  these  remedies  as  the  first  step,  and 
proceeded  afterward  to  add  to  the  treatment,  massage,  electric- 
it  v,  exercise,  and  all  other  practicable  building-up  measures. 
The  result  has  usually  been  favorable.  When  the  gastric  glands 
failed  to  respond,  the  internal  remedies  mentioned  and  all 
attempts  to  re-establish  digestion  in  the  stomach  were  aban- 
doned, but  a  perseverance  with  massage  and  the  other  physical 
or  mechanical  measures  have  almost  uniformly  so  improved 
the  intestinal  digestion  that  the  patients  have  recovered  finally 
a  fair  degree  of  health. 

The  following  cases  indicate  that  massage  in  certain  very 
sensitive  patients  is  capable  not  only  of  aggravating,  but  even 
of  producing  hyperchlorhydria. 

Hyperchlorhydria  Produced  by  Massage. — Case  IIL — 
Neurasthenia  with  chronic  catarrh  and  constipation  in  a 
literary  man,  aged  fifty,  who  would  not  give  up  his  occupation, 
and  often  overworked.  ■  He  had  been  under  treatment  at  times 
during  the  past  three  years.  Tests,  after  the  Ewald  breakfast, 
had  shown  a  small  excess  of  HCl.  After  long  having  had  a 
virtually  normal  gastric  juice,  for  some  time  during  the  past 
autumn  there  had  been  a  deficiency  of  HCl  coinciding  with 
increased  fermentation  in  both  the  stomach  and  intestines  and 
an  unusual  debility.  An  hour  after  the  Ewald  breakfast  on 
December  ist,  there  was  found  to  be  a  total  absence  of  free 
HCl.  He  was  ordered  massage  and  also  dilute  HCl  in  lo-drop 
doses  three  times  a  day,  an  hour  after  each  meal.  The  dose 
was  to  be  added  to  half  a  glass  of  water  and  taken  by  sips  dur- 
ing the  hour  following.  He  did  not  report  again  until  at  the 
end  of  three  weeks,  when  his  medicine  was  discontinued, 
though  the  massage  was  not.  A  day  or  two  later  the  Ewald 
test  Ijreakfast  was  given  him,  and  the  result  showed  the  highest 
degree  of  acidity  ever  found  in  his  stomach  contents — total 
acidity  82,  and  free  HCl  .167.  It  was  afterward  learned  that 
he  had  been  given  an  unusually  vigorous  general  and  abdom- 
inal massage  treatment  at  nine  o'clock  the  night  before,  and 
then  having  awakened  very  early  on  the  morning  of  the  test, 
he  had  tried  the  experiment  of  actively  massering  his  own 


272  METHODS    OF    TREATAIENT 

Stomach  in  the  hope  of  obtaining  another  hour's  nap.  An 
hour  afterward  he  took  the  test  breakfast.  During  the  day 
following  this  test  he  was  required  to  eat  and  drink  exactly 
-,  the  same  as  on  the  preceding  day,  and  to  pursue  the  same 
routine  in  all  respects  except  to  have  no  massage  treatment. 
The  result  was;  total  acidity  46;  free  HCl  .087 — only  a  little 
more  than  half  the  amounts  respectively  shown  by  the  test  of 
the  day  before  after  the  unusual  stimulation  of  the  abdominal 
viscera  by  a  second  massage  treatment  within  about  seven 
hours. 

Hyperchlorhydria  Aggravated  by  Massage. — Case  IV. — 
Marked  neurasthenia  in  a  gentleman,  aged  sixty,  with  a  history 
of  very  excessive  hyperchlorhydria  and  frequently  recurring 
attacks  of  gastralgia  for  several  years.  He  came  under  ob- 
servation early  in  November.  In  this  case  there  is  a  strong 
suspicion  of  gastric  or  duodenal  ulcer.  Various  kinds  of  treat- 
ment had  been  tried  in  New  York  and  elsewhere,  with  tem- 
porary relief  of  the  pain,  but  never  with  any  notable  effect  upon 
the  excessive  secretion  of  HCl,  which  was  said  to  have  been 
on  one  occasion  four  times  the  normal  amount.  My  first  test 
showed  a  total  acidity  of  112,  and  free  HCl  .124.  He  was 
placed  upon  a  diet  as  bland  as  possible  to  be  obtained  in  a  hotel 
and  ordered  a  combination  of  alkalies  to  be  taken  in  moderately 
full  doses  two  hours  after  each  meal.  Massage  was  also 
prescribed  to  be  given  daily  over  the  whole  body  except  the 
stomach,  though  the  masseur  was  directed  to  knead  over  the 
course  of  the  colon  very  gently.  At  the  end  of  eight  days,  a 
second  test-meal  showed  the  total  acidity  to  be  104,  and  the 
free  HCl  .219.  Close  inquiry  elicited  the  fact  that  the  masseur 
had  misunderstood  my  directions  and  been  giving  full  and 
rather  vigorous  massage  over  the  entire  abdomen,  including 
the  stomach.  This  doubtless  accounted  in  the  main  for  the 
aggravation,  though  his  food  had  included  too  much  meat  and 
had  been  more  highly  seasoned  than  was  desirable,  which  must 
have  contributed  to  the  result.  He  was  now  removed  to  a 
private  room  in  a  hospital,  placed  upon  a  most  careful  diet, 
and  no  treatment  of  the  abdomen  permitted  except  the  lightest 
effleurage  over  the  bowels.  Under  these  better  conditions  the 
proportion  of  acid  was  speedily  reduced  to  the  normal,  though 
so  long  as  the  case  remained  under  treatment  it  showed  a 
strong  tendencv  to  rise  again,  requiring  a  continued  use  of 
alkaline  remedies  once  or  twice  a  day  to  hold  it  down.  There 
was  never  a  free  hemorrhage  from  the  stomach  or  bowels,  and 


PASSIVE    EXERCISES^    INCLUDING    MASSAGE  2/3 

no  local  tender  points  could  be  found  either  in  front  or  at  the 
back,  but  there  was  vomiting  as  well  as  much  pain  after  taking 
food,  and  the  existence  of  ulcer  was  quite  possible. 


The  inference  from  the  last  tw^o  cases  is  obvious.  Consider- 
ing the  serious  and  often  disastrous  results  to  health  that  may 
come  from  hyperchlorhydria  with  its  train  of  intestinal  and 
nervous  symptoms,  and  the  readiness  with  which  it  can  be 
greatly  increased  by  massage  of  the  abdomen,  this  powerful 
remedy  should  be  prescribed  with  great  carefulness  and  with 
more  exact  dosage  than  is  now  customary;  and  it  needs  to  be 
remembered  that  in  many  neurasthenic  patients  with  a  tendency 
to  excessive  secretion  of  the  gastric  glands,  even  very  moderate 
massage  over  the  abdomen  can  set  up  this  troublesome  condi- 
tion with  a  resulting  aggravation  of  the  constipation,  as  well 
as  of  the  insomnia  and  all  the  nervous  symptoms. 

Indications  for  Massage  of  Abdomen. — It  may  be  well  here 
to  summarize  in  tabular  form  the  conditions  under  which  mas- 
sage of  the  abdomen  has  been  found  in  my  experience  par- 
ticularly useful : 

1.  Chronic  gastritis  in  all  its  forms  excepting  those  ac- 
companied by  hyperchlorhydria. 

2.  Anacidity  or  subacidity,  except  when  dependent  upon 
acute  gastritis,  carcinoma,  or,  though  this  does  not  often  co- 
exist, ulcer. 

3.  Gastrectasis,  not  dependent  on,  or  associated  with  cancer 
or  ulcer. 

4.  Atonic  conditions  of  the  stomach  walls,  whether 
progressed  to  the  stage  of  dilatation  or  not. 

5.  Displacements  of  the  various  abdominal  organs,  including 
a:  Gastroptosis. 

h:  Nephroptosis,  except  in  cases  in  which  the  displaced 
kidney  has  become  excessively  tender  on  pressure,  and  always 
with  care  to  avoid  manipulating  the  movable  kidney. 

c:  Enteroptosis. 

d:  Hepatoptosis. 


2/4  METHODS    OF    TREATMENT 

6.  Chronic  intestinal  catarrh,  not  compHcated  by  deep  ulcer- 
tion. 

7.  Dilatation  of  the  intestines. 

8.  Chronic  catarrhal  appendicitis. 

9.  Constipation  from  unknown  causes  with  the  exception 
that  deep  or  vigorous  kneading  may  aggravate  the  spastic 
forms  and  those  resulting  from  stricture  or  other  serious 
obstruction.     In  many  cases  massage  alone  cures. 

10.  In  a  group  of  symptoms  which  comprise  especially  ten- 
derness, over  a  region  three  or  four  inches  in  diameter  includ- 
ing the  umbilicus  as  its  center,  and  a  marked  pulsation  of  the 
abdominal  aorta  in  the  entire  epigastric  region.  These  symp- 
toms have  been  assumed,  with  how  much  of  truth  I  am  not 
prepared  to  say,  to  denote  congestion  or  irritation  of  the  solar 
plexus  or  of  one  or  more  of  the  other  plexuses  of  the  abdominal 
sympathetic.  They  are  often  met  with  in  practice  and  may 
be  the  result  of  auto-infection  from  the  gastro-intestinal  tract. 
My  experience  shows  that  these  symptoms  are  usually  benefited 
by  gentle  kneading  of  the  abdomen  in  connection  with  careful 
attention  to  diet. 

The  following  are  the  principal 

Contra-Indications   for   Massage   of  the   Abdomen: 

1.  Ulceration  in  any  part  of  the  stomach  or  intestines. 

2.  Cancer  of  any  of  the  abdominal  organs. 

3.  Acute  inflammation  of  any  abdominal  or  pelvic  organ. 

4.  Hyperchlorhydria,  or  acid  gastritis,  or,  indeed,  any  of  the 
forms  of  excessive  secretion  of  the  gastric  juice. 

5.  Prolapsed  kidneys  which  are  sensitive  to  palpation. 

6.  Aneurism  of  any  of  the  abdominal  or  thoracic  arteries. 

7.  During  the  menstrual  period,  when  the  flow  is  excessive 
or  when  there  is  a  tendency  to  menorrhagia. 

8.  In  fatty  degeneration  or  marked  dilatation  of  the  heart 
and  advanced  phthisis,  especially  with  a  tendency  to  hemop- 
tysis, abdominal  massage  should  be  practiced — if  at  all — with 
much  care  and  gentleness. 

In  addition  to  the  foregoing,  Boas,  on  the  authority  of  Dr. 


PASSIVE    EXERCISES,,    INCLUDING    MASSAGE  2/5 

Zabluclowski  (a  well-known  masseur  and  writer  on  massage  in 
Berlin)  mentions,  as  another  contra-indication,  a  tense  condi- 
tion or  kind  of  tetanic  contraction  of  the  recti  muscles,  which 
is  so  often  seen  in  cases  of  neurasthenia.  In  such  cases,  Zablu- 
dowski  advises  "hands  off."  Zabludowski's  method  (as  I 
happen  to  know  from  personal  experience  of  it,  when,  in  Berlin 
in  1895)  is  one  in  which  tapotement  and  a  peculiar  mixture  of 
violent  slapping  and  vigorous  kneading  predominate.  These 
procedures  would  be  harmful,  of  course,  under  the  conditions 
above  referred  to,  but  the  gentle  stroking  and  kneading  which 
are  given  to  such  patients,  under  my  personal  direction,  have 
been  found  uniformly  helpful  and  curative  to  the  underlying 
disease,  and  at  the  same  time  soothing  to  the  overtense 
muscles. 

Boas  would  also  permit  massage  in  cases  of  gastric  ulcer, 
except  Avhere  adhesive  inflammation  has  attached  the  stomach 
to  adjacent  organs,  and  very  properly  advises  caution  in  mas- 
sering  the  stomach  or  intestines  when  overfilled  with  contents 
or  even  with  gases.  It  seems  to  me,  however,  wiser  to  avoid 
massage  of  the  abdomen  altogether  in  the  cases  in  which  there 
are  positive  signs  or  symptoms  of  ulcer,  and  especially  when 
these  (as  nearly  always  happens)  include  hyperchlorhydria. 

Most  of  the  foregoing  contra-indications  are  self-evident, 
and  need  only  to  be  mentioned. 

In  cases  of  chronic  gastric  catarrh,  it  is  well  to  have  massage 
of  the  abdomen  given  in  the  morning  (fasting),  the  patient 
having  first  taken  one  or  two  glasses  of  water  which  may  be 
medicated  with  some  alkali  or  an  antiseptic  when  advisable. 
This  is  much  less  efficient  in  cleansing  the  gastric  walls  of  the 
adherent  viscid  mucus  than  lavage,  but  may  help  in  patients 
for  whom  the  latter  is  impracticable. 

The  value  of  massage  of  the  abdomen  in  cases  of  malnutri- 
tion associated  with  indigestion  of  atonic  type  and  with 
deficient  secretion  of  the  various  glands  involved,  can  hardly 
be  overestimated.  In  suitable  cases  and  when  properly  given 
under  the  physician's  personal  supervision  it  accomplishes  very 


2/6  METHODS    OF    TREATMENT 

much  more  than  drugs,  stimulating,  as  it  does,  every  gland, 
muscle,  and  other  tissue  within  reach  of  the  operator's  fingers. 
In  this  way  the  metabolic  processes  are  all  quickened.  More 
food  is  transmuted  into  blood  which  in  turn  is  better  purified 
by  a  more  active  elimination  of  the  toxic  products  of  tissue 
metamorphosis,  and  a  larger  amount  of  richer,  purer  blood,  is 
continually  brought  into  contact  with  all  the  structures  acted 
upon. 

In  this  way,  what  was  a  vicious  circle  is  broken  up  and  the 
conditions  are  so  changed  that  the  processes-  can  proceed  with 
more  activity  toward  a  perfect  restoration  of  health. 

The  Rest  Treatment, — The  institution  of  this  method  of 
treating  numerous  cases  of  debilitated  persons  by  Dr.  S.  Weir 
Mitchell,  some  thirty  years  ago,  marked  a  great  advance  in 
therapeutics.  It  has  been  applied  chiefly  in  markedly  neurotic 
or  hysteric  patients,  but  is  well  suited  to  certain  classes  of 
dyspeptics,  especially  those  whose  cases  are  complicated  with 
neurasthenia. 

In  commenting  on  this  method  in  a  recent  editorial  ^  I  used 
the  following  language :  "  By  this  method  such  patients  are 
not  only  given  the  absolute  rest  in  bed  which  is  grateful  to 
many  of  them,  and  helpful  to  nearly  all  of  them,  but,  what  is 
far  more  important,  are  thereby  removed  at  once  from  numer- 
ous actual  or  possible  disturbing  causes— from  mental  strain, 
overexcitement  or  overexertion  of  any  kind,  nagging  cares 
and  worries,  the  temptation  to  dietetic  indiscretions  as  to  food 
or  drink,  late  hours  with  insufficient  sleep  and  dissipation  of 
whatever  form,  w^hether  downright  vicious  and  under  the  ban, 
or  fashionable  and  approved  by  society,  no  matter  how  un- 
hygienic. All  such  dangers,  know^n  and  unknown,  are  cut  off 
at  one  blow  by  the  rest  treatment,  and  many  of  them  are 
particularly  efficient  causes  of  hyperchlorhydria." 

I  might  have  added  with  equal  truth  that  the  method  is  help- 
ful in  the  cases  of  most  women  who  are  at  once  dyspeptic  and 
neurasthenic,  whatever  the  form  oi  the  gastric  derangement 
1  Inf.  Med.  Mag.,  June,  1903. 


PASSIVE    EXERCISES,    INCLUDING    MASSAGE  2// 

may  chance  to  be;  but  with  this  quaHfication  that  when  the 
analysis  of  the  stomach  contents  shows  an  excessive  secretion 
of  HCl,  stimulation  of  the  gastric  glands  by  vigorous  massage, 
as  has  already  been  explained,  is  unsuitable  and  likely  to 
aggravate ;  and  whenever  the  tests  of  the  gastric  motility  in 
such  cases  show  marked  atony  of  the  stomach  walls,  especially 
if  there  be  fully  developed  gastrectasis,  the  large  dependence 
upon  a  milk  diet  which  is  the  usual  routine  in. the  rest  cure, 
would  need  to  be  replaced  by  a  less  bulky  and  more  solid 
diet.  A  form  of  rest  treatment  is  particularly  well  adapted 
to,  and  has  proved  in  large  numbers  of  cases  brilliantly  success- 
ful in,  gastric  ulcer,  in  which  disease  it  is  supplemented  most 
effectually  by  rectal  feeding  at  first  and  later  by  a  liquid  diet, 
chiefly  milk. 


LECTURE  XXV 

ELECTRICITY:  GALVANIC,  FARADIC,  AND 
STATIC— HIGH-FREQUENCY  AND  POLY- 
PHASE    CURRENTS  ^ 

Electricity. — We  are  probably  just  beginning  to  learn  the 
methods  by  which  the  various  forms  of  electricity  may  be 
applied  with  advantage  in  the  treatment  of  diseases  of  the 
stomach  and  intestines.  In  addition  to  the  galvanic  and 
faradic  currents,  which  have  been  increasingly  used  for  many 
years  by  leading  clinicians  in  these  lines,  the  static  spark, 
static  breeze,  and  more  recently  the  secondary  (electrostatic) 
currents  obtained  from  the  static  machine,  for  which  we  are 
indebted  to  Dr.  W.  J.  Morton,  as  well  as  the  so-called  cur- 
rents of  high  potential  and  high  frequency,  are  finding  a  by 
no  means  uniniportant  place  in  the  therapy  of  these  cases. 

With  a  few  exceptions,  even  the  more  recent  works  on  the 
diseases  of  the  digestive  system  do  not  devote  sufficient  atten- 
tion to  the  method  of  applying  these  various  forms  of  elec- 
tricity. 

Continuous  Current,  or  Galvanism. — Central  galvanization, 
i.  e.,  the  continuous  current  passed  through  the  cerebral 
and  spinal  centers,  as  first  described  by  Beard,  is  usually  effective 
in  nervous  dyspepsia  and  the  numerous  nervous  complications 
of  the  indigestions  when  at  the  same  time  proper  attention  is 
given  to  the  diet,  and  a  suitable  apportionment  of  rest  and 
exercise;  but  some  of  the  electrostatic  currents,  and  probably 
mechanical  vibration,  can  now  do  as  much  or  more,  in  skilled 
hands.  Applied  intragastrically,  or  in  sufficiently  large  doses, 
20  ma.  or  more,  externally  through  the  gastric  region,  galvanism 
is  often  effective  in  gastralgia  and  all  the  sensory  derangements 

278 


ELECTRICITY  :    GALVANIC,    FARADIC,    AND    STATIC 


279 


of  the  stomach,  especially  when  dependent,  as  so  many  of  them 
probably  are,  upon  faults  in  the  great  nerve  plexuses  of  the 
sympathetic  system  in  the  abdomen.  Central  galvanization  is 
described  and  illustrated  by  Rockwell,^  and  the  accompany- 
ing cut,  taken  from  the  latest  edition  of  his  work,  gives  a  good 


Fig.  38. — Central  galvanization. 

idea  of  the  procedure.  Moderately  strong  currents  of  10  to  30 
ma.  (and  Doumer  employs  even  100  ma.  wnth  electrodes  6 
cm.  in  diameter),  applied  directly  over  and  to  the  sides  of  the 
abdomen,  have  been  highly  recommended  by  recent  French  writ- 
ers in  the  treatment  of  chronic  intestinal  catarrh,  and  ought  to 
exert  a  curative  influence  upon  chronic  catarrhal  appendicitis  in 
its  earlier  stages.     In  doses  of  i  to  5  ma.  galvanism  has  been 

'  "  Medical  and  Surgical  Electricity,"  by  A.  D.  Rockwell,  A.  M.,  M.  D., 
New  York,  E.  B.  Treat  &  Co.,  1903. 


280  METHODS    OF    TREATMENT 

applied  beneficially  within  the  rectum  for  chronic  proctitis, 
hemorrhoids,  etc.,  though  great  caution  is  recjuired  in  its  appli- 
cation here,  since  damage  can  easily  be  inflicted  by  using  a  dose 
*  relatively  too  large  for  the  sensitiveness  of  the  part  or  the  stage 
of  the  disease.    Small  doses  are  safest  in  this  region. 

Besides  its  value  in  relieving  pain  in  the  stomach,  the  gal- 
vanic current,  applied  intragastrically,  has  also  proved  effica- 
cious in  certain  cases  of  chronic  gastritis. 

Strictures  in  accessible  parts  of  the  alimentary  tube,  as  par- 
ticularly in  the  esophagus  and  in  the  rectum  or  its  vicinity,  are, 
to  some  extent,  amenable  to  treatment  by  a  constant  current  in 
the  form  of  either  a  very  gentle  electrolysis  or  dilatation  with 
metallic  bougies  connected  with  the  negative  pole  of  a  galvanic 
battery,  a  mild  current  of  3  to  5,  and  never  more  than  10  ma., 
being  applied.  Robert  Newman^  claims  to  have  used  this 
method  in  the  urethra  for  thirty-six  years  and  cured  thereby 
2500  cases  of  stricture  in  that  tube  without  a  failure  or  relapse. 
Many  surgeons  claim  to  have  tried  the  same  method  and  failed, 
but  Newman  was  certainly  successful  with  it. ' 

The  Induced  Current,  or  Faradic  Electricity. — This  form  of 
electricity  may  afford  the  greatest  assistance  in  the  treatment  of 
certain  gastro-intestinal  diseases.  Like  central  galvanization, 
what  is  known  as  general  faradization,  alone  or  in  connection 
with  the  former,  proves  often  very  helpful  in  the  treat- 
ment of  all  forms  of  neurasthenia,  including  especially  those 
associated  with  dyspeptic  derangements.  The  technique  of  these 
and  of  the  various  other  methods  of  electric  treatment  is  fully 
described  in  Rockwell's  work  already  cited.  The  faradic  cur- 
rent has  been  found  effective  in  restoring  tone  to  the  debilitated 
abdominal  muscles  as  well  as  the  muscles  of  the  viscera  even 
when  applied  externally,  and  has  proved  particularly  effective 
in  the  latter  direction,  when  brought  directly  in  contact  with  the 
internal  lining  of  the  cavity  to  be  affected.  This  statement  is 
unquestionably  true,  however  the  effect  of  the  electricity  maybe 
explained,  and  quite  regardless  of  the  contention  upon  this  sub- 

"^  Jour,  of  Advanced  Therapeutics,  September,  1903,  p.  554. 


electricity:  galvanic,  faradic,  and  static       281 

ject  as  to  the  possibility  of  producing  contractions  by  electric 
stimulation  of  the  muscles  through  the  mucous  membrane  from 
within  or  through  the  abdominal  parietes  from  without.  It 
matters  little  in  what  way  the  curative  results  obtained  by  elec- 
tricity in  the  stomach  are  produced.  Personally,  however,  I 
believe  that  such  stimulation  does  produce  contractions  of  the 
muscles  in  cjuestion,  since  the  contractions  can  often  be  dis- 
tinctly noted  in  the  human  being.  I  was  the  first  to  publish  the 
observation  that  faradic  electricity,  applied  intragastrically, 
tends  to  lessen  the  secretion  of  the  HCl  in  the  gastric  juice, 
slowly  after  a  primary  stimulation  during  the  earlier  treat- 
ments when  coils  having  coarse  short  wires  are  used,  and  much 
sooner  when  coils  with  long  fine  wires  and  very  rapid, 
smoothly  acting  interruption  are  employed. 

These  last  forms  of  battery  constitute  the  so-called  high  ten- 
sion faradic  apparatus.  But  I  shall  have  more  to  say  of  this 
when  I  come  to  the  subject  of  intragastric  methods. 

Static  electricity  until  very  recently  has  not  been  employed  in 
treating  diseases  of  the  stomach  and  intestines.  Even  now  its 
employment  is  confined  to  a  small  proportion  of  physicians 
who  do  electric  work,  and  few  specialists  in  the  treatment  of 
diseases  of  the  nervous  and  digestive  systems  are  using  it  to 
any  large  extent.  It  affords,  however,  a  most  valuable  addition 
to  our  resources  in  these  affections.  Nervous  dyspepsia  and  the 
various  gastric  and  intestinal  neuroses  are  particularly  suscept- 
ible to  cure  through  its  agency.  Sparks,  the  static  bath  or 
breeze,  the  localized  brush  discharge,  frictional  applications, 
the  static  wave  current,  and  the  static  induced  current  can  any 
of  them  afford  marked  assistance  in  the  treatment  of  certain 
gastro-intestinal  troubles  and  particularly  in  the  nervous  de- 
rangements associated  with  or  dependent  upon  them,  as  well 
as  in  certain  forms  of  renal  diseases  which  result  from  them.^ 
The  long  percussive  sparks  are  applied  to  the  spine  as  a  means 

'  The  Effects  of  the  Secondary  Static  Currents  in  Removing  Albttmin 
and  Casts  from  the  Urine,  with  Reports  of  Cases.  By  Boardman  Reed. 
A»!.  Mcdicme,  November  28,  1903. 


282         ■    •  METHODS    OF    TREATMENT 

of  general  tonic  treatment,  or  to  the  liver,  stomach,  and  lower 
abdomen  over  the  intestines  when  these  are  to  be  aroused  to 
more  energetic  functioning,  especially  the  musculature  of  the 
latter.  The  static  bath  is  a  milder  general  tonic  applicable  to 
cases  which  cannot  easily  bear  the  slight  pain  of  the  sparks, 
while  the  breeze  and  local  brush  discharge  are  suitable  for  the 


Pig.  3g._The  static  electric  machine. 

stimulation  of  regions  winch  are  n.tolerant  of  the  stronger 
spark  applications.     The  static  wave  current    apphed    oh 
entire  spine,  acts  again  as  a  remarkable  general  tome  and  v.al 
stimulant,  and  by  means  of  this  current  a  profound  stmtulafon 


electricity:  galvanic,  faradic,  and  static       283 

of  the  nutrition  can  be  effected  in  any  organ  lying  near  the  sur- 
face of  the  body.  The  static  induced  current  can  do  whatever 
can  be  done  with  the  ordinary  faradic  induced  current,  being 
especially  similar  to  the  high-tension  form  of  the  latter,  but  in 
consequence  of  its  greater  voltage  and  rapidity  of  interruptions, 
the  effect  is  greater. 

Physicians  unfamiliar  w^ith  the  uses  of  static  electricity  and 
totally  ignorant  upon  the  whole  subject  have  sometimes  ex- 
pressed the  opinion  that  the  results  obtained  thereby  are 
psychic  and  due  wholly  to  suggestion.  At  one  time  I  leaned 
to  this  view  myself ;  but  after  being  cured  by  static  sparks  of  a 
very  stubborn  neuritis  for  which  other  therapeutic  measures 
had  failed  to  accomplish  anything,  I  changed  my  mind. 
Moreover,  in  numerous  recent  cases  of  autotoxic  nephritis 
resulting  apparently  from  chronic  indigestion,  I  have  seen  the 
albumin  and  casts  rapidly  removed  by  the  static  wave  current 
and  static  induced  current ;  and  in  one  large  series  of  cases 
analyses  of  the  urine  made  shortly  before  and  after  the  ap- 
plication of  such  currents  showed  an  increase  of  the  urea  at 
the  second  examination  in  every  case  with  a  single  exception. 
Such  clinical  results  and  experimental  data  must  suffice  to  cure 
the  skepticism  of  any  physician  who  is  open  to  conviction. 

High-Frequency  Currents, — High-frequency  currents  are 
among  the  newest  developments  in  the  way  of  electricity. 
They  are  alternating  currents  in  which  the  alternations  are 
prodigiously  rapid.  The  effects  are  in  many  cases  extraor- 
dinary in  the  direction  of  improvement  in  the  nutrition. 
They  produce  almost  no  sensation  in  the  part  to  which  they 
are  applied  except  a  merely  agreeable  warmth  and  feeling  of 
vibration,  and  yet  in  suitable  cases  the  results  are  highly 
favorable.  Their  action  is  similar  to  that  of  the  static  wave 
current,  especially  except  that  they  produce  less  sensation  and 
therefore  can  be  applied  within  the  cavities  of  the  body  quite 
painlessly  and  generally  wnth  benefit  whenever  the  parts  to 
which  they  are  applied  are  in  an  atonic  condition  resulting 
from  imperfect  nutrition.     They  have  already  been  employed 


284 


METHODS    OF    TREATMENT 


largely  in  France  and  England  and  to  a  less  extent  in  this 
country  in  the  treatment  of  atonic  dyspepsia,  gastric  dilatation, 
constipation,  etc.,   and   Herschell  of  London  claims  to  have 


Fig.  40. — Herschell-Dean  triphase  apparatus. 

found  them,  when  applied  within  the  stomach,  even  more 
efficient  in  hyperchlorhydria  than  the  high-tension  faradic 
current,  which  he  has  used  extensively  with  the  help  of  my 
modification  of  the  Einhorn  intragastric  electrode  '^  and  con- 
firmed the  fact  first  observed  and  reported  by  me  that  this 
latter  current  is  effective  in  lessening  hypersecretion. 

1"  Manual  of  Intragastric  Technique,"  by  Geo.  Herschell,  M.  D.,  Lou- 
don, 1903,  p.  147- 


electricity:  galvanic,  faradic,  and  static       285 

Polyphase  currents  are  the  very  latest  form  of  electric 
stimulation  to  be  applied  in  the  treatment  of  disease.  They 
have  been  used  for  several  years  in  France,  and  Herschell  of 
London  has  very  lately  published  a  small  monograph  upon  the 
subject,  besides  having  devised  a  number  of  instruments  and 
apparatus  for  the  application  of  them/  He  employs  the  tri- 
phase  current  especially,  and  claims  for  it  the  power  of  raising 
the  blood  pressure  in  the  numerous  cases  of  neurasthenia 
which  are  characterized  by  a  low  arterial  tension.  He  finds 
it  very  useful  also  in  nervous  dyspepsia,  hyperaesthesia  of  the 
gastric  mucous  membrane,  muscular  atony  of  the  stomach, 
constipation,  and  various  other  gastro-intestinal  affections. 
Indeed,  he  gives  it  the  preference  over  all  other  forms  of  treat- 
ment for  "  restoring  the  tone  to  the  muscular  substance  of  the 
gastro-intestinal  tract." 

\     1"  Polyphase  Currents  in  Electrotherapy,"  by  Geo.  Herschell,  M.  D., 
London,  H.  J.  Glaisher,  1903. 

In  many  cases  of  hyperchlorhydria  in  which  the  derangement  does  not 
depend  upon  ulcer  or  upon  adhesions  of  the  stomach  wall  to  any  of  the 
adjacent  viscera  and  especially  when  the  musculature  of  the  stomach  is 
atonic,  the  current  from  a  high-tension  faradic  coil  applied  directly  to  the 
interior  of  the  organ,  is  more  effective  than  any  other  remedy  as  a  de- 
pressant to  the  excessive  secretion  ;  but  the  above-mentioned  complica- 
tionscontra-indicate  all  intragastric  applications  of  electricity.  Great  care, 
therefore,  to  determine  the  absence  of  such  complications  before  resort- 
ing to  these  methods  should  be  taken  in  every  case,  and  whenever  the 
high-tension  faradic  current  applied  intragastrically  fails  speedily  to 
relieve  hyperchlorhydria,  the  existence  of  some  such  contra-indicating 
1  complication  should  be  suspected  and  another  form  of  treatment  be 
adopted. 

The  ordinary  faradic  current  with  coarse  short  coil  was  at  one  time 
.nuch  employed  within  the  rectum  for  the  relief  of  constipation,  but  used 
,  n  this  way  it  sometimes  irritated  sensitive  rectums  and  vibration  applied 
a  the  same  way  has  proved  both  a  safer  and  a  more  effective  remedy. 


LECTURE   XXVI 

VARIOUS  FORMS  OF  ELECTRIC  AND  HY- 
DRO-ELECTRIC CURRENTS  APPLIED 
DIRECTLY  WITHIN  THE  BOWEL 

The  induced  current  (faradism)  has  long  been  applied 
within  the  rectum  for  constipation  with  good  results,  this 
method  often  relieving  the  condition  and  sometimes  curing  it 
by  stimulating  the  sacral  plexus  as  well  as  the  muscles  directly- 
involved  in  defecation.  Three  to  fifteen  ma.  of  the  continuous 
current  can  be  used  in  the  same  way.  The  negative  pole  is 
usually  applied  within  the  bowel.  More  recently  the  electro- 
static currents  discovered  by  Morton,  the  static  wave  and 
static  induced  currents,  have  been  used  successfully  in 
the  rectum  for  the  cure  of  the  same  disease,  as  well  as  for 
chronic  prostatitis  and  other  affections  not  coming  within  the 
scope  of  these  lectures.  The  very  similar  high-frequency 
currents  of  D'Arsonval  are  employed  in  like  manner  to  effect 
the-  same  ends. 

Dr.  S.  Cohn  of  New  York,  in  a  paper  published  in  the  New 
York  Medical  Journal  of  September  6,  1902,  described  an 
effective  way  of  employing  the  static  currents  in  the  treatment 
of  constipation,  as  follows  : 

"  I  use  static  electricity  either  in  the  form  of  the  wave 
current  or  of  the  static  induced  current ;  the  first  in  the  milder 
forms  of  constipation,  the  latter  in  the  very  obstinate  cases  of 
long  standing.  The  polarity  is  of  importance,  as  the  positive 
pole  has  a  stronger  effect  on  the  tissues  it  is  in  contact  with 
than  the  negative  pole. 

"  In  using  the  static  wave  current  the  patient  is  in  contact 
with  one  pole  only,  while  the  other  one  may  be  grounded  or  not. 


ELECTRIC    AND    HYDRO-ELECTRIC    CURRENTS  287 

If  we  use  a  current  without  grounding,  the  current  is  a  very 
mild  one.  By  grounding  we  make  the  current  considerably 
stronger.  The  contact  is  made  either  by  the  rectum  (the  pa- 
tient sitting  on  the  upright  rectal  electrode)  or  by  the  abdom- 
inal walls  (tinfoil  plate,  8  by  lo).  The  current  strength  is 
regulated  by  the  spark  gap  between  the  sliding  poles. 

"  The  static  induced  current  enables  us  to  use  very  powerful 
means  without  causing  the  patient  any  pain.  The  static 
induced  current  is,  in  reality,  a  current  of  high  tension  and 
high  frequency.  While  the  static  wave  current  distributes  its 
strength  over  the  whole  body,  the  static  induced  current  con- 
centrates its  W'hole  strength  between  two  points  of  the  body. 
The  patient  is  connected  with  the  outer  surface  of  the  Leydeu 
jars,  while  the  inner  surfaces  are  connected  with  the  poles  of 
the  machine.  One  electrode  is  generally  on  the  abdomen,  the 
other  one  either  in  the  rectum  (direct)  or  on  th&  back  (percu- 
taneous). The  current  strength  is  also  regulated  by  the  spark 
gap.  As  the  patient  need  not  be  insulated,  we  can  also  use  the 
labile  method. 

"  The  powerful  action  of  this  current,  as  well  as  that  of  the 
wave  current,  may  be  enhanced  by  a  mode  of  administration 
called  the  undulating  or  swelling  current.  By  this  we  under- 
stand a  current  that,  starting  from  zero,  gradually  swells  to  a 
maximum  of  strength  and  returns  in  the  same  way  to  zero. 
By  alternately  increasing  and  decreasing  this  current,  we 
produce  in  the  muscles  alternations  of  wavelike  contractions 
and  relaxations.  The  efTect  of  this  mode  of  administration 
of'the  current  is  a  tonic  exercise  of  the  muscles,  and,  in  using 
it,  we  do  not  risk  the  danger  of  overworking  and  exhausting 
the  muscles,  as  their  maximum  contractions  are  only  of  short 
\  duration.  The  circulation  of  the  blood  and  lymph  will  cer- 
tainly be  accelerated  by  this  milking-like  process,  and  we  can 
readily  understand  how  the  atonic  condition  of  the  tissues  is 
improved.  On  the  static  machine  we  get  the  swelling  current 
by  slowly  removing  one  pole  from  and  then  approaching  it  to 
the  other." 


255  METHODS    OF    TREATMENT 

Hydro-electric  Applications  within  the  Bowel. — Bondet,  of 
Paris,  originated  the  method  of  applying  the  continuous  cur- 
rent to  the  mucous  membrane  of  the  rectum  and  entire  colon 
with  that  best  of  all  electrodes,  water,  as  the  internal  means 
of  contact  with  the  parts  to  be  influenced,  and  large  flat  elec- 
trodes of  any  convenient  material  for  the  external  one.  It  is  an 
excellent  means  of  treating  chronic  intestinal  catarrh  especially, 
as  well  as  other  intestinal  disorders.  I  found  this  method  in 
use  in  Ewald's  Clinic  in  1895,  and  a  serviceable  apparatus  was 
employed  there  for  the  purpose.  Dr.  Margaret  Cleaves  has 
also  devised  a  good  form  of  apparatus  for  conveying  both 
the  water  and  the  electric  current  into  the  bowel,  and  an  illus- 
tration of  it  is  shown  on  page  289. 

From  a  paper  contributed  by  Dr.  Cleaves  to  the  Interna- 
tional Medical  Magazine,'^  I  reproduce  the  following  extracts 
describing  the  technique  of  applying  this  hydro-electric  treat- 
ment : 

"A  normal  or  physiologic  saline  solution  of  six-tenths  of  i 
per  cent.,  at  a  temperature  of  100°  F.,  is  used,  and  as  it  flows 
into  the  intestine  becomes  the  electrolyte  conveying  the  current 
to  every  part  of  the  mucous  membrane  with  which  it  comes  in 
contact.  The  indifferent  contact  is  made  by  means  of  a  large 
(at  least  forty-five  square  inches  in  area),  well-wetted  electrode 
to  the  hepatic  area  and  abdominal  wall,  or  to  the  lumbar  cord 
and  lumbo-sacral  plexus,  according  to  the  indications  in  each 
individual  case.  If  a  direct  stimulation  to  the  origin  of  the 
nerve  supply  is  paramount  to  the  stimulation  of  atonic  and 
relaxed  abdominal  walls,  the  latter  should  be  used,  otherwise 
the  former ;  and  the  writer  often  uses  a  two-way  contact,  i.  c., 
by  means  of  a  bifurcated  cord  attached  to  both  the  spinal  and 
abdominal  electrodes.  In  this  event  the  greatest  expenditure 
of  energy  will  be  between  the  intestinal  and  spinal  contact, 
because  by  reason  of  the  pressure  from  the  recumbent  position 
as  well  as  by  the  absence  of  fat,  characteristic  of  the  average 
abdominal  wall,  a  better  contact  is  secured  and  resistance  di- 
'  In/.  Med.  Mag.,  October,  1902,  p.  603. 


ELECTRIC    AND    HYDRO-ELECTRIC    CURRENTS  289 

minished.  There  will  also  be  an  expenditure  between  the 
intestinal  and  abdominal  contacts,  but  not  so  great,  by  reason 
of  increased  resistance,  as  in  the  former  instance.  The  indica- 
tions for  the  placing  of  contacts  in  each  individual  case  must 
be  governed  by  the  pathology  of  that  particular  case.  As 
hepatic  torpor,  associated  with  congestion  of  the  liver  and 
congestion,  even  catarrhal  inflammation  of  the  gall-duct  and 
bladder,  exist  very  commonly  in  the  class  of  intestinal  condi- 
tions under  consideration,  the  hepatic  and  abdominal  contact 
is  imperative. 

"  A  long  curved  electrode  of  hard  rubber  may  be  used  or  one 
of  soft  rubber,  as  is  used  in  the  administration  of  a  high  enema. 


Fig.  41. — Dr,  Cleaves'  long  curved  electrode  for  hydro-electric  applica- 
tions within  the  bowel. 

In  the  event  of  disease  at  the  sigmoid  flexure  a  localized  action 
can  be  obtained  at  that  point  by  the  use  of  a  double  current  or 
irrigating  electrode. 

"  By  the  use  of  the  long  electrode,  at  least  eight  inches,  the 
fluid  is  carried  beyond  the  reflexes  governing  defecation,  there- 
by modifying  the  desire  to  empty  the  bowel  during  treatment, 
and  permitting  a  sufficient  expenditure  of  energy  to  secure 
the  desired  result.  With  the  patient  in  position  and  the  body 
contacts  carefully  adjusted,  connection  is  made  between  the 
electrode,  the  hose  of  the  irrigating  jar,  and  with  the  conduct- 
ing cord  from  the  terminal  of  the  battery  indicated  in  the  par- 
ticular case.  The  water  is  then  turned  on  to  permit  of  the 
expulsion  of  air  from  the  electrode  and  also  to  allow  the  water 
which  has  cooled  to  pass  out  of  the  hose.  This  done,  and  a 
little  vaselin  placed  at  the  anus  tO'  facilitate  the  entrance  of  the 
electrode,  it  is  introduced  in  the  same  manner  as  in  an  ordinary 
irrigation  of  the  intestinal  tract.     In  the  introduction  of  the 


290  METHODS    OF    TREATMENT 

electrode  great  care  should  be  taken  to  avoid  pain.  No  forcible 
pressure  should  be  used,  but  it  should  be  allowed  to  glide  easily 
into  position.  This  can  readily  be  accomplished  if  it  is  allowed 
"*  to  follow  the  curves  of  the  bowel,  i.  e.,  toward  the  umbilicus 
for  the  first  one  and  one-half  inches,  then  toward  the  hollow 
of  the  sacrum.  In  the  average  case  there  is  no  pain  or  dis- 
comfort from  its  introduction,  save  just  as  the  bulb  passes  the 
sphincter  ani  muscle.  If  difficulty  is  experienced  the  water 
may  be  turned  on  in  order  to  distend  the  rectum,  thus  facilitat- 
ing the  introduction,  \\lien  this  is  accomplished  and  the  water 
flows  freely,  the  current  is  gradually  turned  on.  Only  such 
a  pressure  or  E.  ]M.  F.  should  be  used  as  is  necessary  to  over- 
come the  resistance  of  the  conducting  circuit,  for  here  a  de- 
structive action  is  not  desired,  but  rather  such  an  expenditure 
of  energy^  as  will  tend  to  establish  nutritive  processes.  This 
extensive  water  electrode,  affording  as  it  does  a  large  square 
inch  area  of  surface,  makes  it  possible  to  secure  by  the  use  of 
a  low  E.  M.  E.  a  large  current  strength,  and  therefore  great 
electric  energ}^  without  pain  or  discomfort.  A  rate  of  flow, 
however,  of  from  i  to  20  or  30  ma.'s  may  be  used  according  to 
the  pathologic  conditions  and  the  patient's  tolerance  of  the  cur- 
rent. Under  no  circumstances  should  the  application  be  carried 
to  the  point  of  pain,  other  than  the  griping  induced  b}-  the  peri- 
staltic action  resulting  from  its  use.  There  are  varying  degrees 
of  tolerance  in  different  patients,  according  both  to  the  pathol- 
ogy and  personal  idiosyncrasies. 

"  If  there  are  adhesive  bands  due  to  an  old  peritoneal  inflam- 
mation, they  are  put  upon  the  stretch  by  the  distention  of  the 
bowel  with  water  and  pain  results.  Care  must  be  taken  not  to 
permit  the  flow  of  sufficient  water  to  cause  pain  and  subsequent 
soreness.  Gradually  the  amount  can  be  increased,  thereby 
securing  greater  current  distril:)Ution,  but  no  sudden  violence 
should  be  done,  nor  should  the  bowel  be  so  distended  at  any 
time  as  to  perpetuate  a  paretic  state.  In  cases  of  colitis,  espe- 
cially if  the  condition  approaches  a  subacute  type,  a  minimum 
expenditure  of  energv  must  be  made,  and  in  many  instances 


ELECTRIC     AND     HYDRO-ELECTRIC     CURRENTS  29 1 

an  amperage  of  from  i  to  5  milliamperes  is  not  only  suffi- 
cient, but  all  that  can  be  tolerated,  while  in  the  average  case 
10  to  20  ma.'s  suffice.  Nothing  is  to  be  gained  by  carrying 
the  application  to  the  point  of  pain,  which  is  an  indication  of 
too  great  and  hurtful  expenditure  of  energy.  In  the  event  of 
an  increase  of  current,  as  the  resistance  is  overcome,  causing 
pain  or  discomfort  to  the  patient,  it  should  be  turned  off  until 
it  is  again  brought  to  the  point  of  the  patient's  tolerance. 

"  The  time  limit  in  these  applications  must  be  governed  by 
the  patient's  ability  to  retain  the  water.  Patients  differ  in  this 
regard.  In  some  cases  a  pint  is  with  difficulty  retained  and  an 
application  of  only  from  three  to  five  minutes  is  possible. 
These  are  the  cases  where  the  lower  bowel  is  more  or  less  filled 
with  hardened  fecal  matter,  which  not  only  prevents  the  elec- 
trode slipping  into  place,  but  obstructs  the  opening  of  the  bulb, 
preventing,  in  the  first  place,  the  free  ingress  of  water  and  in 
the  second  its  passage  be3'ond  the  reflexes  governing  defeca- 
tion. Because  of  this  it  is  good  practice  to  direct  the  patient 
to  take  a  small  rectal  enema  before  coming  for  treatment.  Sub- 
sequent applications  can  be  more  successfully  made.  From  one 
to  three  quarts  of  water  may  be  used  for  from  five  to  ten  min- 
utes before  the  desire  to  empty  the  bowel  becomes  urgent.  In 
pathologic  conditions  characterized  by  extreme  atony  of  the 
intestinal  tract,  a  considerable  cjuantity  of  water  will  be  toler- 
ated on  account  of  the  loss  of  power  in  the  intestinal  coats.  As 
normal  contractility  is  established  a  gradually  lessening  quan- 
tity can  be  retained.  In  all  cases  less  water  should  be  used  in 
successive  administrations.  As  nutritive  changes  are  estab- 
lished in  the  intestinal  tract  with  a  tendency  to  recurrence  of 
normal  peristaltic  movement,  the  desire  to  empty  the  bowel 
comes  much  more  promptly  than  in  the  earlier  applications. 

Measures  to  Combat  Possible  Collapse  from  Sudden  Emp- 
tying of  the  Bowel. — '"  From  the  very  complete  emptying  of 
the  bowel,  which  almost  always  follows  the  first  treatment,  a 
condition  of  more  or  less  profound  collapse  may  arise.  This 
should  be  combated  by  the  administration  of  from  one-half  to 


292  METHODS    OF    TREATMENT 

one  pint  of  hot  water  per  os  and  rest  in  the  recumbent  position. 
This  rarely  occurs  after  the  first  treatment,  and  seldom 
then. 

"  The  current  may  be  reversed  in  order  to  secure  a  more 
stimulating  effect,  or  interrupted.  Sometimes  an  application 
of  the  combined  continuous  and  induced  currents  may  be  made, 
but  the  writer  uses,  as  a  rule,  a  subsequent  application  of  the 
sinusoidal  current  or  a  general  application  of  the  franklinic 
current.  In  the  large  undulatory  or  wavelike  contraction  of 
the  sinusoidal  current  of  low  frequency,  a  slow-moving  stimu- 
lus, fully  applicable  to  the  excitation  of  slow-moving  processes, 
is  obtained.  One  of  three  things  will  promptly  follow  an  intes- 
tinal hydro-electric  treatment ;  first,  a  free  and  complete  evacu- 
ation of  the  bowel,  followed  by  a  sense  of  great  relief,  accom- 
panied in  some  cases  by  more  or  less  severe  collapse ;  second,  a 
certain  amount  of  fecal  matter  may  be  expelled,  with  gas ;  or, 
third,  discolored  water  may  be  passed,  with  or  without  gas. 
In  the  latter  condition  the  treatment  should  be  repeated  in  at 
least  twenty-four  hours,  and  in  intestinal  occlusion  in  from 
seven  to  eight  hours.  In  the  latter  condition  at  least  three 
applications  may  be  made  within  the  twenty-four  hours.  In 
the  chronic  catarrhal  conditions  associated  with  constipation, 
treatment  should  be  given  at  first  every  other  day.  The  fre- 
quency of  the  seances  must  be  governed  by  the  patient's  re- 
sponse. As  soon  as  a  tendency  to  normal  peristalsis  is  estab- 
lished, less  frequent  applications  should  be  made.  The  average 
length  of  time  during  which  treatment  must  continue  depends 
upon  the  nature,  degree,  and  standing  of  pathologic  change,  as 
well  as  the  individual  recuperative  power.  In  the  writer's 
experience  from  one  to  three  months  has  sufficed.  Upon  the 
establishment  of  nutritive  changes  with  a  return  to  normal 
peristalsis,  the  intestinal  treatment  should  be  discontinued,  and 
the  further  management  of  the  case  made  a  matter  of  hygienic 
and  dietetic  detail,  regular  habits,  and  healthful  dress. 

"  In  the  average  case  the  active,  i.  e.,  intestinal  contact, 
should  be  attached  to  the  negative  terminal,  on  account  of  the 


ELECTRIC     AND     HYDRO-ELECTRIC     CURRENTS  293 

characteristic  polar  action.  In  catarrhal  conditions  associated 
with  diarrhea,  a  silver  or  a  copper  wire  may  replace  the  plat- 
inum wire  in  the  electrode  and  the  intestinal  contact  attached 
to  the  positive  terminal.  In  this  way  a  mild  application  of 
either  the  silver  or  the  copper  salt  may  be  made  to  the  intestinal 
mucous  membrane,  and  also  driven  in  cataphorically,  as  well 
as  the  stimulating  and  regenerating  influence  of  the  current 
utilized.  Or,  if  preferred,  the  water  may  be  suitably  medicated 
and  used  at  the  positive  pole. 

The  Hydro-electric  Method  in  Muco-membranous  Enteritis. 
— "  In  the  treatment  of  muco-membranous  enteritis,  the  intes- 
tinal tract  benefits  by  irrigation  with  a  physiologic  saline  solu- 
tion at  its  normal  temperature,  which  frees  the  mucous 
membrane  of  mucous  shreds,  pus  cells  even,  as  well  as  retained 
fecal  matter,  while  by  the  well-known  chemical  action  of  the 
current,  nutritive  changes  are  established  in  the  glandular 
structure,  nerve  centers  stimulated,  circulation  quickened,  and 
absorptive  activity  increased.  Of  a  considerable  number  of 
such  cases  treated,  all  had  run  a  persistently  chronic  course, 
were  characterized  by  irregular  exacerbations,  lack  of  marked 
febrile  excitement,  with  derangement  of  the  intestinal  canal, 
muco-membranous  discharges,  mental  depression,  greatly  im- 
paired health,  also  by  more  or  less  gastric  disturbance,  impaired 
appetite,  repugnance  to  food,  furred  tongue,  and  foul  breath. 
All  were  of  some  years'  standing  and  had  resisted  the  remedial 
agents  administered  from  time  to  time  when  the  subject  of 
medical  attention.  At  the  time  they  passed  from  observation, 
several  months  after  the  discontinuance  of  treatment,  they  had 
normal  appetites,  relief  from  gastro-intestinal  distress,  regular 
l)o\vels,  absence  of  muco-membranous  casts,  and  greatly  im- 
proved general  health.  The  tongue,  which  was  improved  from 
the  first  treatment,  lost  its  coating  and  the  red,  irritable  con- 
dition of  the  sides  and  tips  after  the  second  treatment. 

"  From  six  to  eight  applications  were  made  in  these  cases, 
with  from  lo  to  30  ma.'s  of  current,  the  quantity  of  water 
varying    according    to    individual    tolerance    from    one    pmt 


294  METHODS    OF    TREATMENT 

to   three  quarts.      The   average   seance  was   ten   minutes   in 
length." 

Prerequisites  for,  and  Limitations  of,  the  Hydro-electric 
Method. — The  method  described  by  Dr.  Cleaves  above  requires 
a  good  electric  outfit,  including  a  milliamperemeter,  and,  be- 
sides, the  physician's  office  where  it  is  to  be  carried  out  must  be 
in  close  proximity  to  a  toilet  room ;  but  given  all  these  prerequi- 
sites and  the  necessary  technical  skill  on  the  part  of  the  physi- 
cian, the  mode  of  treatment  yields  often  very  gratifying 
results. 

In  a  number  of  obstinate  cases  dependent  upon  chronic 
colitis,  I  have  found  the  hydro-electric  method  very  effective,  ^^M 
though  exceptionally  troublesome.  When  patients  can  com- 
mand the  services  of  a  thoroughly  expert  masseur,  and  can 
have  in  addition  full  doses  of  the  continuous  electric  current 
passed  through  the  abdomen  from  side  to  side,  equally  good 
results  can  usually  be  obtained.  In  all  cases,  however,  great 
stress  must  be  laid  upon  the  diet.  No  method  of  treatment 
will  succeed  in  effecting  permanent  cures  in  such  cases  unless 
the  patient  can  be  induced  to  change  his  habits  of  living  and 
follow  the  rules  of  hygiene  strictly  in  all  respects.  Provided  the 
diet  is  sufficiently  laxative  and  enough  exercise  of  the  body, 
muscles  is  taken  daily,  almost  any  of  the  forms  of  electricity  ap- 
plied externally  are  usually  effective  in  overcoming  constipation, 
particularly  with  the  help  of  good  massage,  except  when  the 
constipation  is  due  to  a  spastic  condition  or  some  mechanical 
obstruction.  There  is  one  objection  to  the  long-continued  use 
of  water  or  any  watery  solution  in  the  bowel,  whether  accom- 
panied by  electricity  or  not.  This  is  that  thereby  the  peristaltic 
apparatus  is  accustomed  to  a  preternaturally  strong  stimulus, 
and  there  is  thus  danger  that  afterward  the  mere  stimulus  of 
the  presence  in  the  intestines  of  feces,  which  should  normally  | 
be  sufficient  to  produce  evacuations,  may  fail  to  excite  them.  ' 
The  introduction  of  water  or  of  hydro-electric  currents  into 
the  colon  should  therefore  be  strictly  limited  to  cases  in  which 
there  is  a  chronic  catarrhal  inflammation,  which  there  is  hope 


ELECTRIC    AND    HYDRO-ELECTRIC    CURRENTS  295 

of  curing  by  such  means  within  a  few  weeks,  and  then  with 
the  intestinal  mucosa  left  in  a  normal  state,  it  is  often  possible 
to  bring"  about  natural  evacuations  by  simple  hygienic  means, 
including  at  first  a  specially  laxative  diet  and  an  unusual 
amount  of  exercise  of  the  abdominal  muscles. 


LECTURE  XXVII 

OTHER  DIRECT  METHODS  OF  TREATIN' 
THE   INTESTINES 

Those  of  you  who  have  had  most  experience  in  practice  can- 
not fail  to  have  noticed  that  medicines,  especially  when  givei 
by  the  mouth,  usually  fail  to  accomplish  much  in  the  treatmeni 
of  chronic  intestinal  diseases,  whether  they  take  the  form  of 
constipation  simply  or  of  chronic  enteritis  with  frequent  alter- 
nations of  constipation  and  diarrhea,  and  in  either  case  a! 
plentiful  array  of  nervous  symptoms  which  yield  to  no  kind 
of  therapy  until  the  underlying  cause  has  been  removed.  You 
should  not  be  surprised,  therefore,  at  the  number  of  unusual 
methods  which  have  been  devised  to  remedy  these  complicated 
and  always  stubborn  conditions.  I  am  acquainting  you  with 
the  technique  of  the  more  effective  of  such  methods,  most  of 
which  seem  to  have  proved  remarkably  successful  in  the  hands 
of  those  who  devised  and  have  become  expert  in  the  use  of 
them,  though  other  clinicians,  who  are  not  so  expert  with  them, 
have  often  been  less  fortunate  in  getting  good  results. 

Carbon  Dioxide  in  Diseases  of  the  Rectum  and  Colon. — Dr. 
A.  Rose  ^  of  New  York  strongly  recommends  the  use  of  injec- 
tions of  carbonic  acid  gas  into  the  rectum  for  ulcers,  fissures, 
and  catarrhal  affections  of  the  rectum  as  well  as  for  ulceration 
or  catarrh  of  the  colon.  Rose  thus  describes  his  method  of 
disengaging  and  administering  the  gas : 

"  I  have  tried  and  have  suggested  carbonic  acid  gas  infla- 
tion of  the  rectum  in  enteritis  membranacea,  and  in  the  few 
cases  I  have  thus  far  treated  in  this  manner  the  results  have 
been  gratifying,  but  I  am  not  prepared  to  publish  my  observa- 
^  Int.  Med.  Mag.,  October,  1902,  p.  617. 
296 


METHODS    OF    TREATING    THE    INTESTINES  297 

tions,  because  none  of  these  cases  could  be  diagnosticated  as 
pure  enteritis  membranacea.  One  was  complicated  with  gen- 
eral neurosis,  spasm  of  the  pylorus  and  morphinismus ;  in  an- 
other there  existed  well-pronounced  splanchnoptosis ;  and  in 
none  of  these  cases  was  the  treatment  confined  to  the  applica- 
tion of  carbonic  acid  gas  alone.  However,  from  theoretic 
reasons,  we  are  justified  in  giving  the  carbonic  acid  inflation  a 
trial  in  enteritis  membranacea. 

"  In  the  course  of  time  I  have  experimented  with  different 
kinds  of  apparatus,  and  afterwards  I  have  fallen  back  upon  the 
one  I  first  made  use  of,  because  it  has  the  advantage  over  the 
others  that  it  can  be  easily  improvised,  as  a  rule,  with  the  aid 
of  a  nearby  druggist.  It  consists  of  a  bottle  holding  a  pint 
or  a  little  less,  with  a  wide  neck  and  a  rubber  stopper  perforated 


Fig.  42. — Rose's  apparatus  for  generating  carbonic  dioxide. 

so  as  to  admit  a  tube,  with  a  nozzle,  as  the  case  may  be,  for 
nose,  rectum,  or  vagina.  (See  illustration.)  A  solution 
of  about  six  drams  of  bicarbonate  of  soda  in  about  six 
or  eight  ounces  of  cold  water  is  introduced  into  the 
bottle,  and  four  drams  of  crystallized  tartaric  acid  (if 
pulverized  acid  is  used  the  development  of  the  gas  goes 
on  too  rapidly)  are  added.  The  larger  these  crystals  are 
the  better.  Instead  of  the  tartaric  acid  crystals,  disks  of 
acid  sulphate  of  soda  may  be  used.  The  bottle  is  then  closed, 
and  the  carbonic  acid  developing  in  the  water  rises  through  the 
tube,  the  nozzle  of  which  has  been  placed  in  position.  The 
form  of  gas  generated  serves  quite  well  to  apply  the  gas  to  the 


298  METHODS    OF    TREATMENT 

nasal  cavities,  to  inflate  the  rectum,  and  in  some  instances  it 
can  be  used  to  g'ive  vaginal  gas  douches.  Gas  develops  during 
about  ten  to  twelve  minutes.  Its  disadvantage  is  that  the  cur- 
rent of  gas  can  neither  be  regulated  nor  interrupted,  but  in  case 
this  should  be  desirable,  we  may  attach  a  reservoir  in  the  shape 
of  a  rubber  bag  in  which  the  gas  is  made  to  enter  and  from 
which  the  flow  can  be  regulated  at  will. 

"  A  few  seconds  after  the  gas  enters  the  rectum  there  is 
produced  a  sensation  of  warmth,  then  a  slight  desire  to 
evacuate  the  bowel,  which  immediately  passes  away.  In  pa- 
tients who  avoid  pressure  and  control  the  levator  there  is  no 
voiding  of  gas,  the  muscular  closure  sufficing  to  retain  it, 
except  after  the  intestine  has  taken  up  to  its  full  capacity.  The 
abdomen  gradually  becomes  expanded  and,  when  the  patient 
begins  to  complain  of  tension,  the  administration  is  discon- 
tinued, or  the  patient  is  at  liberty  to  void  the  gas.  After  the 
gas,  or  a  certain  amount  of  it,  has  been  voided,  the  inflation 
may  be  resumed.  As  a  rule,  I  continue  inflation  with  or  with- 
out interruption  for  about  five  minutes ;  patients  accustomed  to 
the  procedure  may  endure  it  for  a  somewhat  longer  time.  Car- 
bonic acid  gas  may  be  employed  then  with  perfect  impunity. 
When  the  inflation  is  carried  out  ad  maximwn  the  lower  part 
of  the  abdomen  becomes  expanded,  the  abdominal  walls  are 
under  great  tension,  but,  notwithstanding,  the  liver  is  not  at 
all,  or  only  very  slightly,  pushed  upward;  on  percussion  over 
this  organ  the  dullness  remains  about  as  before ;  there  is  no 
raising  of  the  diaphragm,  consequently  no  retraction  of  the' 
lungs ;  no  dyspnoea  is  observed ;  no^  cyanosis.  Persons  experi- 
mented on  may  complain  of  disagreeable  tension  of  the  abdom- 
inal walls,  but  even  this  unpleasantness  disappears  more  and 
more  as  the  patient  becomes  accustomed  to  inflation." 

Turck's  Colonic  Treatment. — Professor  Fenton  B.  Turck 
of  Chicago  advocates  the  use  of  what  he  denominates  "  pneu- 
matic massage  "  for  the  colon  as  well  as  for  the  stomach.  He 
describes  the  procedure  as  follows : 

"  In  one  of  the  experiments  quoted  above  of  Me3'-er  and 


METHODS    OF    TREATING    THE    INTESTINES 


299 


Prebriam,  attention  was  called  to  the  effect  npon  the  heart  and 
circulation  by  distention  of  the  stomach  with  air.  If  the  disten- 
tion continues,  a  fall  in  blood  pressure  occurs,  and  collapse  may 
ensue,  but  I  have  found  that  after  distending  the  stomach  or 
colon,  if  the  air  is  allowed  immediately  to  escape  through  the 
tube,  the  blood  pressure  will  not  only  return  to  normal,  but 
there  results  a  marked  improvement  in  the  circulation.     This 


Fig.  43. — Turck's  apparatus  for  pneumatic  gymnastics. 


improvement  is  not  confined  to  the  walls  of  the  stomach  or 
colon,  but  influences  all  the  abdominal  vessels.  I  therefore 
adopted  the  use  of  air  instead  of  water,  as  a  form  of  exercise 
for  the  stomach  and  colon,  to  which  I  gave  the  name  '  Pneu- 
matic Gymnastics,'  and  '  Gymnastic  Massage.'  ^ 

"  The  method  is  very  simple.  The  air  is  forced  into  the 
stomach  or  colon  through  the  introduced  double  or  single  soft 
rubber  tube,  preferably  the  double  tube.     Either  an  atomizing 

^  Turck,  Methods  of  Diagnosis  and  Therapeutics,  Jour.  Amer.  Med. 
Assoc,  June  22,  1895  ;  ibid..  Am.  Med.  and  Surg.  Bull.,  July  i,  1895  ; 
Modern  Methods  of  Treatment  of  Diseases  of  the  Intestines,  TV.  Y,  Med. 
four.,  March  13  and  20,  1897  ;  Pneumatic  Gymnastics,  Brit.  Med.  Jour., 
October  28,  1895,  p.  1328. 


300  METHODS    OF    TREATMENT 

bulb  or  the  air  from  a  compressed  air  tank  is  used.  As  I 
previously  stated  {Jour.  A.  M.  A.,  June  22,  1895)  'the  in- 
troduction of  the  air  distends  the  stomach  and  contraction 
forces  the  air  out  through  the  other  tube,  so  that  we  have  a 
pneumatic  massage.'  I  have  called  attention,  not  only  to  this 
method  of  treatment  of  the  stomach,  but  also  of  the  colon  as 
follows  {Airier.  Med.  and  Surg.  Bull.,  July  i,  1895)  :  '  By  the 
introduction  of  air  through  one  tube  and  its  exit  through  the 
other  tube,  it  acts  as  a  "  pneumatic  massage  "  and  does  not 
stretch  or  overdistend  the  alread}^  weakened  .organ.  The  effect 
of  the  treatment  is  also  immediate,  and  two  weeks  will  often 
show  a  marked  improvement.  It  may  be  used  in  the  stomach 
or  colon,  and  the  nebulized  cloud  can  be  forced  into  the  in- 
testines ;  and  when  hydrogen  gas  is  used,  the  whole  intestinal 
tract  can  be  treated.' 

"  The  method  of  using  heated  air,  moist  or  dry,  and  medi- 
cated when  desired,  I  have  repeatedly  shown  is  an  additional 
advantage  in  this  method  of  pneumatic  gymnastics  of  the 
stomach  or  colon.  Steam  or  vapor  introduced  at  a  temperature 
of  55°  C.  is  a  vaso-motor  stimulant.  Gas  and  air  have  been 
previously  used  in  the  stomach  and  intestines,  principally  for 
diagnostic  purposes.  Von  Ziemssen  was  among  the  first  to 
advocate  the  use  of  COo  for  distending  the  stomach  and  colon 
to  facilitate  examination.  Senn  used  hydrogen  gas  for  the 
purpose  of  locating  intestinal  perforations.  CO2  introduced 
into  the  stomach  has  also  been  used  for  its  therapeutic  effect, 
and  HjS  forced  into  the  intestine  was  supposed  to  possess 
medical  properties.  The  intestines  have  been  inflated  for 
therapeutic  purposes  to  overcome  obstruction. 

"  But  the  pneumatic  gymnastics  which  I  have  advocated  is 
an  entirely  different  procedure,  and  depends  upon  a  different 
principle.  The  pneumatic  gymnastics  of  the  colon  may  be 
combined  with  abdominal  massage  (when  not  contra-indi- 
cated), which  helps  to  force  out  the  air.  This  improves  the 
circulation  at  once.  It  is  especially  indicated  in  atony  as- 
sociated with  constipation." 


METHODS    OF    TREATING    THE    INTESTINES  30I 

Turck's  Method  of  Doing  Lavage  of  the  Colon. — Turck  is 
also  a  strong  advocate  of  the  injection  alternately  of  hot  and 
cold  water  into  the  colon  for  the  purpose  of  stimulating  the 
circulation  in  the  whole  splanchnic  area  and  has  in  many  cases 
undoubtedly  produced  excellent  results  in  this  way.  To 
obviate  the  irritation  which  water  and  most  medicated  solu- 
tions are  liable  to  produce  in  the  bowel  he  employs  an  infusion 
of  slippery  elm,  which  is  not  only  soothing,  but  has  been  found 
by  him  to  be  a  poor  culture  medium  for  germs.  The  same 
infusion  he  recommends  for  lavage  of  the  stomach  also. 

Flushing  of  the  Colon. — The  practice  of  washing  out  the 
colon  by  the  injection  every  day  or  every  other  day  of  large 
quantities  of  warm  water,  several  quarts  or  even  gallons  in 
some  cases,  while  a  valuable  resource  sometimes  for  emer- 
gencies, is  most  injurious  in  its  effects  when  long  continued 
or  regularly  depended  upon  for  the  evacuation  of  the  bowels 
in  chronic  constipation.  I  cannot  warn  you  too  strongly 
against  this  fad,  which  was  introduced  into  use  in  this  country 
many  years  ago  by  a  layman,  and  for  a  time  vaunted  as  an 
extraordinary  means  of  promoting  health  and  longevity.  I 
know  of  no  more  certain  means  of  causing  an  obstinate  form 
of  constipation  with  finally  dilatation  of  the  colon.  It  is,  how- 
ever, an  effective  method  of  unloading  quickly  the  bowels  when 
these  have  long  been  neglected — i.  e.,  as  a  preliminary  to  more 
rational  methods  of  treatment.  In  chronic  colitis,  too,  a 
moderate  flushing  of  the  colon,  with  medicated  solutions  for  a 
limited  time,  will  often  prove  effective  in  modifying  the 
catarrhal  process.  I  have  seen  good  results  from  the  use  of 
the  following  prescription  for  two  or  three  weeks  at  a  time, 
together  with  abdominal  massage  and  other  appropriate  treat- 
ment : 

^    Acid,  carbol 3  iss 

Glycerin , §  iii 

Listerin  q.  s.  ad |  vi 

M.  S.     Two  tablespoonfuls  in  two  quarts  of  cool  or  tepid  water  by 
enema  every  other  night. 


2,02  METHODS    OF    TREATMENT 

Dr.  Deardorff  ^  of  San  Francisco,  who  first  suggested  the 
above  prescription,  advises  that  such  an  enema  be  employed 
every  akernate  evening  for  a  few  weeks  and  that  the  bowels  be 
evacuated  by  means  of  an  enema  of  the  normal  salt  solution  on 
the  other  evenings.  A  better  way  is  to  rely  upon  the  injection 
of  two  to  six  ounces  of  olive  or  cottonseed  oil  to  secure  evacu- 
ations on  the  nights  when  the  medicated  enema  is  not  used. 
Indeed,  since  I  have  learned  the  great  value  of  even  quite  small 
doses  per  rectum  of  any  one  of  the  bland  vegetable  oils  in 
overcoming  constipation  when  persevered  with  for  weeks  or 
months,  if  necessary,  and  carried  out  in  connection  with  a 
suitable  diet,  gymnastic  movements  and  some  mechanical 
measures  for  the  stimulation  of  the  nerve  centers  and  muscular 
apparatus  concerned  in  defecation,  I  find  that  these  are 
generally  all-sufficient  for  the  cure  of  the  milder  cases  of 
constipation,  especially  in  patients  who  are  not  very  old,  with 
very  little  medicine  introduced  at  either  end  of  the  alimentary 
tube. 

Technique  of  Administering  Oil  Enemas — This  method, 
which  comes  to  us  from  Germany,  has  a  very  large  weight  of 
authority  in  its  favor  and  is  as  harmless  as  it  is  effectual  in  not 
only  relieving  both  atonic  and  spastic  constipation,  often  un- 
aided, but  in  finally  curing  it,  when  the  patient  will  eat,  drink, 
exercise,  and  live  in  all  ways  hygienically,  though  in  stubborn 
cases  other  measures  are  valuable  auxiliaries.  Let  the  patient 
have  ready  prepared  before  rmdressing  at  bedtime  two  to  eight 
ounces  of  some  bland  oil  warmed  to  the  body  temperature. 
This  can  be  best  introduced  by  means  of  a  glass  or  metal 
reservoir  and  an  ordinary  short  semiflexible  rectal  tube  con- 
nected by  rubber  tubing.  It  will  be  safer  to  begin  with  the 
smaller  dose  and  gradually  increase  till  the  dose  is  reached 
which  produces  a  sufficiently  full  evacuation.  The  reservoir 
containing  the  oil  should  not  be  hung  at  a  height  of  more 
than  two  or  three  feet  above  the  patient.  Then,  when  fully 
ready  to  retire,  let  him  lie  down  on  the  left  side  with  a  pillow 
!/«/.  Aled.  Mag.,  May,  1899,  p.  354. 


METHODS    OF   TREATING   THE    INTESTINES  3O3 

under  the  hips  and  slowly  inject  the  oil,  being  careful  to  lie 
quietly  in  the  same  position  till  all  desire  to  evacuate  the  oil  has 
ceased.  After  lying  on  the  left  side  for  a  few  minutes,  he 
should  turn,  and  thereafter  during  the  night  lie  mostly  on  the 
right  side.  At  first  it  may  be  desirable  to  keep  a  folded  towel 
against  the  anus  during  the  night  to  prevent  the  bed's  being- 
soiled,  but  persons  having  a  normally  tight  sphincter  will  not 
find  this  necessary.  When  there  is  a  persistent  pressure  to 
have  the  enema  expelled  it  may  be  because  of  impacted  feces 
in  the  rectum,  which  should  be  removed  by  one  or  two  thorough 
colon  flushings  in  the  beginning  of  the  treatment.  If,  in  spite 
of  this  precaution,  the  oil  will  not  remain  in  the  bowel  during 
the  night,  it  may  be  advisable  exceptionally  to  employ  a  long 
soft  rubber  rectal  tube  with  which  to  introduce  the  oil,  and 
have  skilled  assistance  in  passing  it  well  up  into  the  colon 
where,  with  care  to  see  that  the  patient  lies  for  some  time  on 
the  right  side  after  retiring,  it  will,  as  a  rule,  give  no  further 
trouble  till  it  comes  away  in  the  morning  with  a  soft  or  normal 
evacuation  of  feces — often  a  copious  one.  You  should  care- 
fully direct  the  patient  to  let  the  injection  of  the  oil  be  the  very 
last  thing  done  before  getting  into  bed,  since,  when  he  is 
obliged  to  get  up  and  go  about  the  room  afterward,  the  oil  may 
not  be  retained.  In  cases  of  pronounced  colitis  it  is  often 
better  still  to  mix  with  the  oil  just  before  injecting  it  from  half 
to  one  teaspoonful  of  the  subcarbonate  of  bismuth.  This  in- 
creases the  soothinsf  and  healing  effects  of  the  oil. 


LECTURE  XXVIII 

VIBRATION,  MANUAL  THERAPY,  AND 
OTHER  :\IECHANICAL  FORMS  OF  TREAT- 
MENT 

jMechanical  vibration  is  an  old  method  of  general  and  local 
stimulation  which  has  been  much  employed  in  the  larger  in- 
stitutions such  as  that  of  the  government  in  Baden  Baden,  in 
the  numerous  Zander  institutes  of  Europe  and  America,  and 
in  some  of  the  principal  sanitariums  of  this  country.  Lately 
ingenious  forms  of  apparatus  have  been  devised  and  put  upon 
the  market  for  the  purpose  of  more  conveniently  regulating  the 
application  of  vibration  to  the  spine,  joints,  and  other  regions 
and  cavities  of  the  body,  including  the  rectum,  vagina,  etc. 
There  is  so  far  less  literature  upon  this  subject  than  could  be 
desired,  but  I  believe  that  in  the  future  the  method  will  be 
more  thoroughly  studied  and  found,  for  application  in  certain 
localities  of  the  body,  superior  to  stimulation  by  means  of 
electricity. 

The  late  Dr.  ]\Iaurice  F.  Pilgrim  of  X'ew  York,  a  former 
vice  president  of  the  American  Electro-Therapeutic  Associa- 
tion, and  therefore,  presumably  an  expert  in  the  therapeutic 
uses  of  electricity,  recently  wrote  a  book  on  "  Alechanical 
Vibratory  Stimulation."  ^  He  was  a  very  enthusiastic  advo- 
cate of  the  method,  giving  it  the  preference  over  electricity  in 
many  cases  for  which  local  or  general  stimulation  is  indicated. 

The  recent  investigations  of  physiologists  demonstrating 
that  vaso-constrictor  and  vaso-dilator  nerve  fibers  pass  out 
from  the  spine  with  the  various  spinal  nerves  and  go  finally 
to  control  the  caliber  of  the  smaller  arteries  and  arterioles  in 

'  "  Mechanical  Vibrator}^  Stimulation,"  b}'  ]\Iaurice  F.  Pilgrim,  M.  D.. 
New  York,  The  Lawrence  Press,  no  Fifth  Avenue. 

304 


MECHANICAL  FORMS  OF  TREATMENT  305 

the  periphery  and  the  viscera,  have  afforded  an  apparent 
scientific  basis  for  all  the  forms  of  local  stimulation,  especially 
over  the  regions  on  either  side  of  the  spine,  which  before  rested 
merely  upon  empiricism.  Hence  the  greatly  increased  activity 
and  zeal  displa3^ecl  now  in  the  propagation  of  such  methods.  I 
have  been  the  more  willing  to  put  to  the  test  the  claims  made 
in  behalf  of  vibratory  stimulation  from  the  fact  that  it  is 
almost  identical  in  principle  with  the  vibratory  movement  in 
hand  massage,  only  capable  of  more  delicate  and  varied  as  well 
as  more  vigorous  and  sustained  application,  and  very  similar 
to  the  stimulation  produced  by  electricity  which  I  have  been 
applying  to  the  spine,  as  well  as  to  the  other  parts,  for  over 
thirty  years  with  excellent  results.  I  studied  the  effects  of 
mechanical  massage,  including  vibration  as  formerly  employed 
in  a  cruder  way  in  Baden  Baden,  in  1885,  and  in  the  Battle 
Creek  Sanitarium  in  1893,  and  then  received  a  favorable  im- 
pression as  to  its  value.  It  possesses  some  real  advantages 
over  other  forms  of  mechanical  treatment  now  that  apparatus 
for  applying  it  has  been  so  perfected  that  it  can  be  conveniently 
and  effectively  employed  in  any  office  which  is  in  connection 
with  an  electric  light  plant.  By  means  of  some  of  the  im- 
proved instruments  for  applying  vibration,  treatments  varying 
in  force,  as  well  as  in  the  length  of  the  vibratory  movement, 
can  be  given  conveniently  and  effectively  to  any  external  part  of 
the  body  and  to  several  of  the  accessible  cavities.  Dr.  Pilgrim 
gives  the  following  summary  of  the  advantages  claimed  for 
mechanical  vibration : 

"  Treatment  by  mechanical  vibratory  stimulation  has  been 
found  by  practical  experiment  to  be  capable  of : 

"  (1)    Increasing  the  volume  of  the  blood  and  lymph  flow 
to  a  given  area  or  organ ; 

"  (2)    Increasing  nutrition ; 

"  (3)   Improving  the  respiratory  process  and  functions; 
■  "  (4)    Stimulating  secretion; 

"  (5)   Improving   muscular   and   general   metabolism,    and 
increasing  the  production  of  animal  heat; 


3o6 


METHODS  OF  TREATMENT 


"  (6)    Stimulating  the  excretory  organs  and  assisting  the 
functions  of  ehmination ; 

"  (7)    Softening  and  reheving  muscular  contractures; 
"  (8)    Relieving  engorgement  and  congestion; 


Fig.  44. — A  vibrator. 


"  (9)  Facilitating  the  removal  through  the  natural  channels 
of  the  lymphatics,  of  tumors,  exudates,  and  other  products  of 
■inflammation;  relieving  varicosities  and  dissipating  eruptions; 

"  (10)    Inhibiting  and  relieving  pain." 

The  method  is  especially  applicable  in  atony  of  the  stomach 
and  intestines  both  secretory  and  motor,  and  the  stimulation 
can  be  advantageously  r.pplied  either  directly  in   front  over 


MECHANICAL  FORMS  OF  TREATMENT  307 

the  abdomen  or  to  the  corresponding"  areas  on  either  side  of 
the  spine  over  the  nerves  which  supply  the  parts  involved. 

Various  forms  of  manual  therapy  have  come  into  vogue 
within  recent  times,  including  osteopathy,  mechano-neural 
therapy,  chiropraxis,  naturopathy,  etc.  These  have  agreed  in 
condemning  all  methods  of  treatment  except  their  own,  claim- 
ing that  medicines  are  entirely  useless  and  harmful  in  every 
case,  and  that  by  means  of  various  kinds  of  manipulations 
many  of  them  similar  to  those  of  the  familiar  Swedish  move- 
ments and  massage,  all  the  curable  diseases,  both  acute  and 
chronic,  can  be  cured.  The  osteopaths,  more  rational  appar- 
ently than  the  other  sectarians  named,  have  virtually  abandoned 
these  extravagant  claims,  and  in  many  of  their  schools  materia 
medica  as  well  as  pathology,  bacteriology,  and  the  other  funda- 
mental branches  indispensable  to  an  educated  and  competent 
physician,  are  now  being  taught.  They  devote  particular  at- 
tention to  the  deviations  of  the  vertebrae  and  other  faults  in  the 
spine  which  are  too  often  neglected  by  physicians  generally 
(except  by  the  regular  orthopedic  surgeons),  and  seem  to  ac- 
complish good  results  in  some  cases  of  chronic  ill-health  due  to 
such  faults  afflicting  especially  persons  engaged  in  sedentary  oc- 
cupations from  long  sitting  or  working  in  cramped  positions. 
Indeed,  these  practitioners  have  become  largely  spine  special- 
ists, but,  according  to  my  observations,  fail  generally,  as  do,  in 
fact,  the  majority  of  practitioners  of  all  the  so-called  schools,  to 
recognize  and  correct  the  enormously  frequent  and  very  im- 
portant displacements  of  the  abdominal  viscera.  If  anything 
of  value  in  the  osteopathic  or  other  exclusive  methods  has  not 
hitherto  been  practiced  by  our  masseurs,  masseuses,  nurses,  and 
bath-attendants,  it  should  be,  and  assuredly  will  be,  hereafter 
taught  them,  so  that,  under  the  supervision  of  broadly  and 
properly  trained  physicians,  any  needed  mechanical  treatments 
can  be  given.  (See  pp.  83  and  255.)  Certain  it  is  that 
neither  the  naturopathists  nor  any  other  of  the  sects  can  prop- 
erly claim  a  monopoly  of  our  natural  forces,  sunlight,  water, 
exercise,  diet,  etc.     We  all  use  them. 


308  METHODS  OF  TREATMENT 

Numerous  writers  have  in  late  years  discussed  the  anatomic 
and  physiologic  foundations  for  the  treatment  of  the  different 
organs  through  the  spinal  nerves  at  their  origins.  One  claim 
made  by  Arnold/  as  well  as  by  Pilgrim  in  the  book  previously 
cited,  is  that  in  many  neurasthenics  as  well  as  in  numerous 
other  patients  affected  with  disease  in  some  of  the  thoracic  or 
abdominal  organs,  a  peculiar  change  can  be  recognized  by  the 
touch  in  the  muscles  alongside  the  spinal  vertebrae  correspond- 
ing to  the  origin  of  the  nerves  supplying  the  affected  part. 

By  allowing  the  patient  to  lie  down  upon  one  side,  while  you 
feel  along  the  upper  side  of  the  spine  gently  with  the  tips  of 
the  fingers,  you  may  detect  frequently  instead  of  the  normal 
soft  mass  of  muscular  fiber  running  parallel  to  the  spine  on 
either  side,  a  cord-like  structure  which  feels  hard  and  tense 
under  the  fingers.  Whenever  such  a  cord-like  band  can  be  felt 
there  is  said  by  Pilgrim  to  be  a  contracted  or  possibly  atrophic 
state  of  the  tissues  beneath,  and  usually  the  patient  finds  palpa- 
tion over  such  a  place  more  or  less  painful.  Frecjuent  treatment 
of  these  morbidly  affected  parts  by  mild  electric  applications, 
or  by  mechanical  vibratory  stimulation  (probably  also  by  man- 
ual treatment),  will  often  remove  the  abnormal  condition  and 
at  the  same  time  the  unusual  sensitiveness  to  pressure  with 
simultaneous  improvement  in  the  condition  of  the  organs  or 
parts  supplied  by  the  nerves  arising  from  the  adjacent  parts 
of  the  spinal  cord. 

Counter-irritants. — The  actual  cautery,  blisters,  rubefaci- 
ents, wet  and  dry  cupping,  etc.,  have  been  in  use  since  the 
earliest  times  as  means  to  modify  the  blood  supply  of  parts  di- 
rectly underneath  or  adjacent  to  the  site  of  application.  The 
fact  that  they  occasionally  influence  the  circulation- in  more 
distant  parts  has  been  frequently  observed,  as  when  hyper^emia 
of  the  brain  or  pelvic  organs  has  been  lessened  by  immersing 
the  feet  in  hot  mustard  water.  Such  effects  have  doubtless 
been  due  in  part  to  a  reflex  stimulation  of  the  vaso-motor 
centers  and  in  part  only  to  a  direct  derivation  of  an  excess  of 
'^Interti.  Med.  Mag.,  for  May,  July,  and  August,  1903. 


MECHANICAL  FORMS  OF  TREATMENT  309 

blood  from  the  part  to  which  the  appHcation  is  made.  Coun- 
ter-irritants can  be  made  highly  useful  as  palliatives,  partic- 
ularly in  various  gastro-intestinal  affections;  and  the  remedy 
which  can  only  palliate  in  stubborn  chronic  conditions  can  often 
cure  the  same  when  of  recent  origin. 

Heat  and  Cold. — These  agents  act  in  much  the  same  way  as 
the  foregoing,  and  are  of  even  wider  applicability.  The  great 
value  of  ice  packs  to  the  abdomen  in  peritonitis  and  appen- 
dicitis need  not  be  dwelt  upon  here.  Hot  wet  packs  applied 
over  the  epigastrium  or  lower  abdomen  also  exercise  a  power- 
ful sedative  influence  upon  the  circulation  in  the  viscera  under- 
neath. These  agents  might  have  been  more  appropriately  in- 
cluded under  the  head  of  hydrotherapy,  except  that  they  are 
not  always  applied  in  the  form  of  water  or  ict  or  the  vapor  of 
water.  Dry  heat  in  the  form  of  hot  air,  hot  bottles,  and  hot 
bricks  is  often  used  for  the  same  purpose,  but  usually  is  not 
nearly  as  efficacious  as  the  hydriatic  methods  of  applying  it. 

Hydriatic  Procedures. — Numerous  volumes  have  been  writ- 
ten upon  the  various  forms  of  hydrotherapy,  and  it  will  be  im- 
possible to  go  deeply  into  so  large  a  subject  in  this  connection. 
Suffice  it  to  say  that  we  have  few  more  powerful  means 
of  influencing  the  circulation  and  nutrition  in  any  part  of  the 
body,  including  of  course  the  digestive  organs,  than  by  a  skill- 
ful use  of  water  and  the  various  hydriatic  applications.  I  shall 
have  more  to  say  to  you  about  this  under  the  head  of  the  dif- 
ferent diseases  to  be  discussed  in  subsecjuent  lectures,  and  an 
abundance  of  literature  is  accessible  upon  the  subject,  including 
especially  the  works  of  Dr.  Simon  Baruch  ^  and  Dr.  J.  H. 
Kellogg-  in  this  country. 

Phototherapy,  or  the  Finsen  Light  Treatment,  has  also  been 
proved  useful  by  numerous  observers  in  gastro-intestinal  af- 
fections. Exposure  of  the  body  to  the  sun's  rays  has  been 
found  tonic  and  restorative  in  adynamic  conditions  generally; 
and  there  is  apparently  no  good  reason  why  the  sun's  rays 

■•"Uses  of  Water  in  Modern  Medicine,"  Detroit,  Geo.  S.  Davis,  1892. 
^"  Rational  Hydrotherapy,"  J.  H.  Kellogg,  F.  A.  Davis  Co.,  Phila.,  1901. 


3IO  METHODS  OF  TREATMENT 

should  not  be  concentrated  and  reflected  into  the  rectum  for 
the  treatment  of  hemorrhoids  and  rectal  ulcers  as  well  as  for 
ulceration  in  the  larynx  or  disease  of  the  cervix  uteri. 

Similarity  of  the  Effects  of  the  Different  Mechanical 
Methods. — Most  of  the  mechanical  modes  of  treatment  tend 
to  produce  like  effects.  Electricity,  hydriatic  procedures, 
exercise  in  the  form  of  special  gymnastic  movements  and  mas- 
sage both  manual  and  mechanical,  the  former  including  all 
the  forms  of  manipulation  and  pressure  over  the  spinal  nerve 
origins  and  over  the  lymphatic  as  well  as  other  glands,  and  the 
latter,  especially  vibratory  stimulation  over  the  same  important 
regions,  are  different  means  of  exciting  to  more  vigorous,  or 
at  least  more  healthful,  action  ( i )  the  great  lymphatic  system 
with  its  vitally  important  eliminative  function,  which  is  often 
sluggish  in  its  work  in  sedentary  persons,  or  congested  and 
blocked  by  an  excess  of  detritus  from  neighboring  abscesses, 
inflammatory  exudates  or,  more  exceptionally,  malignant 
growths  undergoing  resolution  as  a  result  of  x-ray  treatment ; 
(2)  the  vaso-motor  system  of  nerves  and  the  intimately  as- 
sociated sympathetic  chain  of  ganglia  which  dominate  the 
blood  supply  and  secretory  and  excretory  work  of  all  the  vis- 
cera, including  especially  the  digestive  organs  as  well  as  the 
blood  supply  of  all  other  parts  of  the  body;  (3)  the  secretory 
glands  of  the  abdominal  organs  through  the  stimulation  (or 
inhibition  in  certain  cases)  by  mechanical  vibration,  manipula- 
tion, or  electric  applications  along  the  spine,  of  secretion  in  the 
different  viscera  by  means  of  which,  in  the  case  of  the  liver  and 
intestines,  with  the  help  of  stimulation  also  of  the  peristaltic 
apparatus,  more  thorough  evacuations  of  the  bowels  can  be 
effected  and  constipation  often  be  cured;  (4)  the  muscular 
system  generally  by  direct  local  excitation  as  well  as  through 
the  nerves  supplying  the  muscles,  thus  increasing  the  develop- 
ment of  the  latter  and  augmenting  their  vastly  important 
work  in  metabolism,  heat  production,  etc.;  (5)  the  skin,  the 
activity  of  the  circulation  and  sweat  glands  of  which  is  es- 
sential to  the  healthy  functioning  of  the  digestive  organs;  and 


I 


MECHANICAL  FORMS  OF  TREATMENT  3II 

(6)  the  kidneys,  the  chief  emunctories  of  the  body,  any  inter- 
ference with  whose  action  not  only  seriously  embarrasses  di- 
gestion, but  also  endangers  life  itself.  Abundant  physical 
exercise  alone  in  the  hardy  laborer,  whose  work  is  out  of  doors, 
accomplishes  all  these  results  without  care  or  forethought. 
Massage  can  also  go  far  toward  maintaining  all  the  functions 
in  a  healthy  state,  or  restoring  them  when  disturbed  by  minor 
derangements.  Hydrotherapy  can  often  keep  the  skin  active 
and  healthy  and  invigorate  the  circulatory  and  nervous  systems, 
when  none  of  the  organs  are  seriously  diseased,  but  though 
usually  helpful  in  nervous  dyspepsia,  generally  fails  when  de- 
pended on  alone  to  remedy  structural  disease  in  the  gastro- 
intestinal tract.  The  various  forms  of  electricity  and  the 
newer  developments  in  vibratory  stimulation  I  have  already 
seen  accomplish  excellent  results  which  make  me  hopeful  of  the 
future. 

Treatments  Through  the  Spine. — As  to  treatment  through 
the  spine,  I  have  had  some  experience  in  that  direction  with 
electricity,  vibration,  hydriatic  methods,  and  counter-irritants, 
all  of  which  have  been  found  to  help  much  at  times  in  disease 
of  the  digestive  organs.  Dr.  Albert  Abrams  of  San  Francisco, 
a  distinguished  regular  physician  of  large  experience,  and  the 
author  of  numerous  books,  has  just  borne  emphatic  testimony 
to  the  good  results  which  can  be  accomplished  by  these  as  well 
as  by  more  novel  methods  of  influencing  the  viscera  through 
their  nerve  supply.  He  has  published  a  new  work,  which  is 
the  most  scientific  and  at  the  same  time  the  most  practical  which 
has  yet  appeared  on  this  subject.^  He  treats  it  in  a  broad  and 
comprehensive  way,  giving  particular  directions  for  acting 
upon  the  lungs,  heart,  and  arteries,  and  the  abdominal  viscera 
through  the  spine  by  means  of  either  electricity  or  concussion 
of  the  vertebras  with  plexors.  Yet,  unlike  most  other  ad- 
vocates of  similar  treatments,  he  does  not  ignore  the  great 
value  of  the  appropriate  medicinal  remedies  in  many  cases. 

^  Spondylotherapy ;  Spinal  Concussion  and  the  Application  of  other 
Methods  to  the  Spine  in  the  Treatment  of  Disease.  By  Albert  Abrams, 
M.  D.,  (Univ.  of  Heidelberg).    San  Francisco:  The  Philopolis  Press.    1910. 


LECTURE   XXIX 

INTRAGASTRIC  METHODS  OF  TREAT- 
MENT—LAVAGE,  INTRAGASTRIC  SPRAY, 
ETC. 

When  and  How  to  Wash  Out  the  Stomach. — The  "  when  " 
involves  these  questions:  (i)  in  what  cases,  (2)  how  often, 
and  (3)  at  what  time  of  the  day.  The  first  is  the  most  diffi- 
cult to  answer.  Lavage  helps  many  cases  in  a  most  striking 
manner.  In  others,  apparently  similar,  it  fails  and  may  do 
harm.  Sidney  Martin,  while  bearing  testimony  to  its  great 
benefit  in  certain  conditions,  says :  "  The  method  of  treatment 
has  been  much  abused  and  must  be  applied  with  circumspec- 
tion." Ewald  hit  the  nail  on  the  head  in  his  paper  before  the 
British  Medical  Association  when  he  cautioned  against  the 
"  too  long  continuance  and  too  frequent  employment  of  wash- 
ing out  the  stomach,"  adding  that  "  when  it  does  good,  it  does 
so  very  soon." 

The  tube  is  far  more  valuable  for  diagnosis  than  for  treat- 
ment. In  all  your  cases  of  indigestion  and  often  in  neuras- 
thenia, constipation,  insomnia,  and  especially  in  stubborn  head- 
aches, you  would  do  well  to  ascertain,  by  means  of  an  analysis 
of  the  stomach  contents  under  varying  conditions,  exactly 
what  sort  of  work  the  organ  is  doing  as  to  its  secretory  func- 
tion, and  also  gain  full  information  about  its  even  more  im- 
portant motor  function. 

When  such  tests  show  a  large  amount  of  mucus,  you  may 
suspect  gastric  catarrh,  and  in  most  cases  of  chronic  catarrhal 
inflammation  of  the  stomach  itself,  lavage  will  do  good ;  in 
many  of  them  it  is  almost  indispensable. 

More  often  the  mucus  comes  from  the  parts  above,  having 

312 


INTRAGASTRIC    METHODS   OF  TREATMENT  313 

been  swallowed,  and  the  diagnosis  of  chronic  gastric  catarrh, 
which  many  physicians  attempt  to  make  offhand,  frequently 
presents  difficulties,  even  with  the  help  of  chemical  and  micro- 
scopic examinations  of  the  stomach  contents.  But  this  sub- 
ject will  be  considered  in  a  subsequent  lecture. 

The  most  imperative  indication  for  lavage  is  gastrectasis,  or 
dilatation  of  the  stomach,  whether  resulting  from  narrowing 
of  the  pyloric  orifice  (cancer  or  other  tumors,  or  the  cicatrix 
of  an  ulcer),  from  a  kink  of  the  small  intestines  (which  may 
follow  displacement  of  the  stomach,  colon,  or  right  kidney), 
or  from  atony  of  the  muscular  walls  of  the  organ.  Whatever 
the  cause,  dilatation,  when  neglected,  tends  to  become  a 
serious  condition,  and  lavage  judiciously  done  is  an  aid  to 
the  cure  in  the  atonic  cases,  while  it  is  a  most  valuable  pallia- 
tive in  the  desperate  ones,  until  operative  relief  can  be 
obtained. 

In  bad  cases  of  gastric  catarrh  and  in  patients  not  too 
reduced  in  strength,  provided  all  the  results  are  encouraging, 
it  will  be  proper  to  wash  out  every  day  at  first,  until  the 
amount  of  mucus  is  markedly  lessened.  This  will  be  the 
more  advisable  if  the  microscope  shows  the  presence  of 
numerous  yeast  fungi  or  sarcinse  in  the  wash  water.  As  the 
conditions  improve,  or  sooner  if  the  patient  should  fall  off  in 
flesh,  tone,  or  appetite,  prolong  the  intervals,  until  by  the  end 
of  a  month,  once  a  week  may  be  often  enough. 

When  the  treatment  has  been  begun  early  and  is  properly 
carried  out,  you  will  often  succeed  in  removing  all  the 
symptoms  and  signs  of  gastritis  in  one  or  two  months;  but 
1  in  very  advanced  or  debilitated  cases  you  will  need  to  be 
guided  by  the  effects,  and  sometimes  in  such  cases,  with  dila- 
tation dependent  upon  a  mechanical  obstruction  of  the  outlet, 
a  radical  cure  is  not  practicable.  The  best  that  can  be 
accomplished  then,  under  ordinary  conditions,  without  oper- 
ative interference  is  palliation,  and  for  this  you  may  find  it 
useful  to  cleanse  away  the  accumulated  mucus  and  bacteria,  at 
least  once  a  week  during  the  remainder  of  life. 


314  METHODS    OF    TREATMENT 

Best  Time  for  Lavage. — In  nearly  all  cases  the  best 
time  for  lavage  is  before  breakfast.  At  this  time  remains  of 
digested  food  are  very  rarely  found  in  the  stomach  to  be 
washed  away  and  lost  to  the  system,  except  in  the  worst  cases 
of  dilatation.  It  is  a  most  inconvenient  hour  for  the 
physician,  but  it  is  usually  practicable  to  have  nurses  trained 
so  as  to  do  the  work  with  all  necessary  skill.  A  good  nurse 
can  report  intelligently  as  to  the  macroscopic  appearance  of 
the  wash  water,  and  in  all  important  cases  she  should  from 
time  to  time  save  samples  of  it  for  microscopic  examination — 
a  little  of  the  first  brought  up  for  examination  as  to  the 
amount  of  mucus  and  presence  of  bacteria,  and  some  of  the 
last  to  be  tested  as  to  the  presence  of  degenerated  epithelium 
from  the  gastric  mucous  membrane.  My  own  custom  is  to 
employ  the  electric  centrifuge  to  obtain  a  concentrated  sedi- 
ment for  this  purpose. 

Many  good  authorities  advise  that  lavage  be  done  at  bed- 
time when  fermenting  food  in  the  stomach  prevents  sleep. 
This  may  exceptionally  be  useful,  especially  in  cases  of  gas- 
tralgia,  but  diseased  stomachs  are  rarely  empty  at  bedtime 
and  experience  teaches  that,  as  a  continuous  practice,  washing 
away  half-digested  food  is  disastrous.  When  severe  fermen- 
tation cannot  be  otherwise  controlled,  it  would  be  better  to 
feed  less  b}^  the  stomach  and  help  out  by  nutritive  enemas. 

How  to  wash  out:  The  way  to  introduce  the  tube  is 
fully  described  in  Lecture  VII.  Don't  procure  any  of 
the  complicated  apparatus  for  lavage  you  will  see  described  in 
the  books.  They  are  all  troublesome  and  unsatisfactory. 
Lavage,  according  to  my  experience,  is  best  carried  out  with  a 
simple  soft  rubber  stomach  tube,  in  size  about  No.  32  of  the 
French  scale.  It  should  be  provided  with  an  opening  directly 
in  the  end  and  with  one  large  opening  about  half  an  inch 
above.  It  is  also  advisable  to  have  a  number  of  openings  about 
pin-head  size  near  the  end  so  as  to  produce  a  sprinkler  effect 
upon  the  walls  of  the  stomach  when  the  fluid  is  poured  in 
and  also  to  insure  a  continuous  return  flow  in  spite  of  the 


INTRAGASTRIC   METHODS  OF  TREATMENT  31$ 

possible  blocking  of  the  larger  openings  by  pieces  of  food. 
The  tube  should  be  about  four  and  a  half  feet  long  and  have 
fitted  into  its  upper  end  a  large  glass  funnel,  when  to  be  used 
for  the  purpose  of  lavage,  and  a  bulb  in  the  course  of  it  helps 
to  keep  it  clear.  It  is  also  desirable  to  cut  off  about  one  foot 
of  the  upper  end  and  insert  a  piece  of  glass  tube  four  inches 
long  to  serve  as  a  fenestra,  so  that  you  may  observe  when  the 
water  is  flowing  in  or  out  without  interruption.  The  tube 
should  be  made  of  highly  polished  rubber  and  should  be  dis- 
carded whenever  cracks  have  occurred  in  it,  since  these  are 
liable  to  irritate  some  portion  of  the  mucous  membrane. 
After  use  the  tube  should  be  thoroughly  cleansed  with  hot 
water  and  afterward  allowed  to  stand  for  some  time  in  a  5 
per  cent,  solution  of  formalin  in  order  thoroughly  to  disin- 
fect it.  If  you  have  not  analyzed  the  stomach  contents  and 
do  not  know,  whether  hydrochloric  acid  is  deficient  or  in 
excess,  it  will  be  safer  for  you  to  use  tepid  or  warm  (not  hot) 
water  which  has  been  sterilized  by  boiling,  with  bicarbonate 
of  sodium  dissolved  in  it  to  the  extent  of  one  or  two  teaspoon- 
fuls  to  the  Cjuart.  If  the  treatment  should  be  continued  longer 
than  a  month,  and  you  remain  in  ignorance  as  to  the  gastric 
secretion,  it  will  be  best  to  omit  even  the  soda  after  that  time 
and  wash  out  with  boiled  water  only.  If  an  analysis  has 
shown  that  you  are  dealing  with  an  acid  gastric  catarrh  (in 
which  the  glands  secrete  an  excess  of  HCl  and  the  ferments  as 
well  as  of  mucus)  you  can  dissolve  a  tablespoonful  of  soda  to 
the  quart  of  water  and  go  on  with  this  for  a  long  time,  pro- 
vider! the  hyperacidity  persists  and  the  patient  is  improving 
in  nerve  tone.  But  don't  mistake  the  familiar  sour  stomach 
of  fermenting  carbohydrates  for  hyperacidity  from  an  excess 
of  HCl.  In  the  former  condition  the  prolonged  use  of  alka- 
lies is  very  hurtful. 

When  there  is  a  marked  deficiency  of  HCl,  the  water  may 
Ije  hotter  and  table  salt,  from  a  teaspoonful  to  a  tablespoonful, 
may  1je  added  to  each  quart.     Exceptionally,   stronger  anti 
septics  or  astringents  may  be  used.     The  most  serviceable  I 


3i6 


METHODS    OF    TREATMENT 


have  found  to  be  alum,  one-half  teaspoonful,  and  nitrate  of 
silver,  one  or  two  grains,  to  the  quart.     Strong  HCl,  a  half 


Fig.  45. — Lavage  of  the  stomach.     Inserting  the  tube. 

teaspoonful  to  the  quart,  will  often  answer  well,  when  there 
is  a  marked  deficiency  of  gastric  juice. 

Many  other  drugs,  including  boric  acid,  salicylic  acid,  tannic 
acid,  resorcin,  and  alumnol  are  employed  in  this  way,  but  all 
of  them,  and  especially  the  stronger  ones,  are  liable  to  have 
an  injurious  action  when  continued  long.  It  is  a  safe  rule, 
and  one  which  I  try  to  follow,  never  to  use  for  lavage  more 
than  four  times  as  much  of  any  drug  as  could  be  safely  left 


INTRAGASTRIC   METHODS   OF  TREATMENT 


Z^7 


to  absorb,  since  one-fourth  will  often  pass  into  the  bowel  and 
be  absorbed. 

The  tube  with  the  funnel  inserted  in  it  having  been  intro- 
duced, the  solution,  previously  prepared  and  placed  in  a  pitcher 


Fig.  46. — Lavage  of  the  stomach.     Pouring  the  solution  into 
the  funnel. 

at  hand,  is  poured  in,  a  pint  or  quart  at  a  time.  Just  before 
the  last  of  the  water  has  disappeared  from  the  funnel  the  latter 
should  be  carried  quickly  down  toward  the  floor  and  held  in 
the  upright  position  over  a  pail.  By  siphonage  the  liquid 
now  flows  back  into  the  funnel,  where  it  may  be  inspected 


3i8 


METHODS    OF    TREATMENT 


before  emptying.  One  quart  of  water  is  quite  as  much  as 
most  patients  will  care  to  have  used  at  the  first  washing  or 
,  two,  but  later  you  should  gradually  increase  the  cpantity,  until 
finally  several  cjuarts,  or  enough  to  cleanse  away  all  the  mucus, 
may  be  introduced,  but  not  more  than  one  quart  at  a  time, 
and  in  some  very  weak  stomachs  a  pint  at  a  time  will  be  more 
advisable.  Be  careful  always  to  get  out  again  all  the  water 
you  put  into  the  stomach,  especially  when  medicated,  or  at 
least  as  much  of  it  as  has  not  passed  on  into  the  duodenum. 

A  practical  wa-inkle,  which  I  have  found  to  lessen  consider- 
ably the  time  recjuired  to  loosen  and  detach  all  the  mucus  in 
old  gastric  catarrhs,  is  to  have  the  patient  drink  a  tumbler  or 
two  of  warm  water  before  taking  the  tube,  and  then,  lying 
down  on  the  back,  make  voluntary  contractions  of  the  ab- 
dominal muscles  so  as  to  splash  the  water  around  in  the 
stomach  for  three  to  five  minutes.  When  this  is  done,  scarcely 
one-half  the  usual  quantity  of  water  is  required  in  the  washing 
out  which  follows  directly  afterward. 

Delicate  patients  should  be  allowed  to  rest  in  the  recumbent 
position  half  an  hour  at  least  after  lavage,  and  in  no  case 
should  a  meal  be  eaten  within  that  time  after  the  pro- 
cedure. 

The  Intragastric  Douche  and  Spray. — Various  devices  are 
in  use,  both  in  Europe  and  in  this  country,  as  substitutes  for 


Fig.  47. — Turck's  stomach  sprinkling  tube. 


lavage.  These  include  what  are  virtually  stomach  tubes  with 
numerous  small  openings  at  the  end,  through  which  water  or 
any  medicated  fluid  can  be  forced  in  fine  jets  so  as  to  cleanse 
the  walls  of  the  viscus  and  either  stimulate  or,  in  suitable 
cases,   soothe  and  medicate  them.     Turck  employs   for  this 


INTRAGASTRIC    METHODS   OF  TREATMENT 


319 


purpose  what  he  calls  the  sprinkling  tube  or  needle  douche,  an 
illustration  of  which  is  here  given. 

It  consists  of  a  double  tube,  the  shorter  of. which  has  its 
lower  end  perforated  with  numerous  small  holes.  When 
water  is  forced  in  through  this  tube,  either  by  elevating  the 
reservoir  some  twelve  feet  high  or  employing  a  force  pump, 
the  mucous  membrane  of  the  stomach  should  be  effectually 
cleansed  by  t?ie  numerous  fine  jets  impinging  upon  it.  Turck 
claims  that  when  hot  and  cold  water  are  used  alternately — 
115°  to  45°  F. — the  action  is  that  of  a  powerful  vaso-motor 
stimulant.  The  longer  tube  serves  for  the  outflow,  keeping 
the  stomach  empty.     This  is  a  useful  apparatus. 

Einhorn  has  invented  a  special  apparatus  for  spraying  the 
inner  walls  of  the  stomach  with  medicated  solutions,  claiming 


Fig.  48. — Einhorn's  intragastric  spray  apparatus. 


that,  on  account  of  the  very  much  smaller  dose  of  any  toxic 
agent  thus  required  to  medicate  the  whole  mucous  membrane, 
the  risk  of  a  poisonous  effect  is  avoided. 

He  employs  the  ordinary  spray  apparatus,  except  that 
Ijetween  the  bottle  and  terminal  spraying  nozzle  a  sufficient 
length  of  a  small  soft  tube  is  inserted  to  extend  from  a  con- 
venient point  outside  the  mouth  to  the  interior  of  the  stomach. 
Air  is  then  forced  through  the  apparatus  in  the  usual  way  by 


320  METHODS    OF    TREATMENT 

compression  of  a  rubber  bulb  with  the  hand.  This  has  a 
less  cleansing  effect  than  either  lavage  or  Turck's  needle 
douche,  but  affords  a  very  useful  means  of  disinfecting  or 
'otherwise  medicating  the  mucous  membrane  of  the  viscus. 
The  spraying  is  only  effective  when  the  stomach  is  empty, 
and,  if  necessary  to  secure  this  condition,  lavage  should 
precede  it. 


1 


LECTURE  XXX 

INTRAGASTRIC    METHODS,  CONTINUED— 
INTRAGASTRIC    ELECTRICITY 

The  most  strikingly  favorable  results  I  have  observed  from 
any  form  of  instrumental  treatment  in  the  stomach  have  been 
from  the  use  of  faradism  with  an  electrode  inside  the  viscus. 
The  direct  application  of  electricity  to  the  stomach  from  within 
is  entirely  practicable  with  the  instruments  now  obtainable, 
and  it  may  surprise  some  of  you  to  learn  that  it  is  an  even 
simpler  procedure  than  lavage.  Notwithstanding  some  state- 
ments to  the  contrary,  during  the  past  fifteen  years  there  has 
accumulated  a  large  array  of  evidence,  both  experimental  and 
clinical,  in  this  country  and  elsewhere,  to  the  fact  that  direct 
electrization  of  the  stomach  through  an  electrode  within  the 
viscus,  the  current  being  completed  by  the  application  of  the 
other  pole  either  to  the  back  or  the  epigastric  region,  can  cause 
contractions  of  its  walls  and  a  diminution  of  its  size.  There 
is  clinical  testimony  also  from  a  number  of  observers  to  the 
fact  that  the  innervation  and  secretory  function  of  the  stomach 
can  be  powerfully  influenced  in  the  same  way. 

As  Simple  as  Lavage. — Lest  it  be  inferred  that  the  method 
must  be  complicated  and  difficult,  one,  therefore,  which  could 
have  only  a  remote  interest  for  general  practitioners,  let  me 
say  to  you,  and  emphasize  it  as  strongly  as  possible,  that  intra- 
gastric electric  treatment  is  at  least  as  simple  as  lavage,  pro- 
ducing even  less  strain  upon  a  weak  or  nervous  patient,  and 
for  persons  accustomed  to  the  tube,  unless  in  a  case  of  gastric 
ulcer  or  cancer  for  which  it  is  wholly  unsuited,  is  by  no  means 
so  dangerous  in  its  possible  consequences,  when  wrongly  used, 
as  are  drugs  recklessly  and  unskillfully  prescribed. 

321 


3^2  AIETHODS    OF    TREATMENT 

This  is  so  true  that,  with  the  instrument  and  method  now 
employed  for  this  purpose  in  my  practice,  I  not  only  advise 
family  physicians  how  to  overcome  atonic  conditions  and 
dilatations  of  the  stomach  by  this  means,  but  also  instruct 
nurses,  and  in  exceptional  cases  even  the  relatives  or  friends 
of  patients,  so  that  they  can  administer  the  treatment  safely 
under  my  general  supervision. 

This  means,  of  course,  that  the  method  has  been  much 
simplified  since  the  earlier  experiments  with  it.  Dr.  Charles 
G.  Stockton  of  Buffalo  was  the  first  in  America  to  employ 
electricity  in  this  manner,  having  begun  using  it  in  1887.  He 
devised  a  very  ingenious  electrode,  which  he  has  continued  to 
use  up  to  the  present  time  with  excellent  resuls.  It  was  fully 
described  in  a  paper  by  him  in  1891.^ 

He  has  seen  markedly  curative  effects  in  cases  of  stomachs 
with  weakened  or  apparently  absent  motility,  in  gastric  dilata- 
tion, catarrh,  atrophy  and  in  "  some  in  which  the  hydrochloric 
acid  existed  in  excess." 

Intragastric  Electrodes. — For  several  years  the  intragastric 
electrode  devised  by  Einhorn  was  employed  to  some  extent 
in  my  practice  and  occasionally  with  strikingly  good  results, 
especially  in  a  few  cases  of  very  marked  dilatation  without 
pyloric  stenosis.  Some  difficulty,  however,  was  experienced 
in  introducing  it  into  the  stomach  of  occasional  patients  on 
account  of  the  considerable  diameter  of  the  terminal  bulb  con- 
taining the  electrode  and  the  absence  of  any  stiffness  in  the 
cord  or  rheophore.  Ewald  obviated  this  in  part  by  covering 
the  very  flexible  cord  with  a  medium-sized  rubber  tube  fitted 
neatly  to  the  bulb.  Thus  a  very  slight  degree  of  stiffness  was 
produced,  sufficient  to  permit  of  the  electrode's  being  gently 
pushed  down  in  patients  who  could  not  otherwise  swallow  it. 
I  found  this  modification  in  use  in  Ewald's  clinic  in  Berlin  in 
1895,  and  brought  one  home  with  me.  It  rendered  good 
service  for  a  time  till  it  wore  out.     Then  recourse  was  had  to 

•  The  Use  of  the  Gastric  Electrode  in  Diminished  Peristalsis,  by  Charles 
G.  Stockton,  M.  D.,  Medical  Times  a7id Register,  November  7,  1891. 


INTRAGASTRIC    METHODS   OF  TREATMENT 


323 


the  original  Einhorn  instrument,  and  upon  extending  its  em- 
ployment to  a  large  number  of  cases,  including  some  with 
very  nervous  throats,  several  difficulties  were  encountered. 
The  instrument  resembles  a  large  capsule  with  a  flexible  cord 
attached,  and  a  few  patients  who  were  accustomed  to  the 
stomach-tube  and  able  to  take  the  largest-sized  capsule  by 
itself,  insisted  that  they  could  not  swallow  one  with  a  string- 
to  it.  There  was  at  times  still  more  trouble  in  getting  the 
electrode  up  again.  The  bulb  would  catch  in  the  narrowest 
part  of  the  esophagus  and  fail  to  pass  through,  even  with  the 
aid  of  deglutition-movements.  Then  the  patient  in  such  a 
contingency  would  sometimes  grasp  the  cord  and  give  it  a 
hard  tug,  with  the  result  of  breaking  the  very  fine  wires  inside. 
In  these  cases  it  was  sometimes  necessary  to  insert  the  fore- 
finger down  behind  the  larynx,  disengage  the  electrode  and 
draw  it  out. 

An  illustration  of  the  original  electrode  invented  by  Pro- 
fessor  Einhorn,   and  largely 
used     in     all     parts     of     the 
United    States,    is    herewith 
shown. 

I  have  had  this  instrument 
modified  so  as  to  render  it 
easier  both  to  introduce  and 
to  withdraw,  and  now  rarely 
have  any  difficulty  in  admin- 
istering electricity  directly 
within   the   stomach. 

Great  credit  is  due  Professor  Einhorn  for  originating  his 
very  serviceable  electrode,  and  I  do  not  claim  any  for  so  modi- 
fying it  as  to  make  it  better  suit  my  needs ;  but  the  fact  that  the 
modified  instrument  is  in  some  respects  an  improvement  on  the 
original  would  appear  evident  from  the  description  of  the 
original  just  given  with  that  of  the  modification  which  fol- 
lows, as  well  as  from  the  accompanying  illustrations  of  both. 

Reed's    Modification    of    the    Einhorn    Electrode. — In    the 


Fig.  49. — Einhorn's  intragastric 
electrode. 


324 


METHODS    OF    TREATMENT 


modification  the  bulb  or  capsule  covering  the  bit  of  metal 
which  constitutes  the  electrode  proper  is  much  narrower,  as 
well  as  longer  and  more  sloping  at  both  ends,  than  that  of  the 
Einhorn  and  Ewald  instruments,  so  that  it  is  easier  both  to 
introduce  it  into  the  stomach  and  to  get  it  out  again,  which  is 
equally  important.  The  cord  is  composed  of  spiral  wire  cov- 
ered thinly  with  rubber,  and  has,  like  the  Ewald  electrode, 

enough  firmness  to  enable  it  to  be 
gently  pushed  through  a  spasmodi- 
cally contracted  esophagus,  and  yet  is 
so  small  as  not  to  provoke  usually 
any  marked  flow  of  saliva.  It  does 
not  prevent  talking  or  drinking,  or 
otherwise  annoy  the  majority  of  pa- 
tients during  the  five  to  eight  minutes 
that  each  treatment  must  last.  These 
are  all  extremely  practical  points  in 
carrying  out  the  method  •  in  nervous 
or  fussy  patients. 
Turck's  gyromele  is  capable  of  being  used  as  an  electrode, 
but  I  have  not  employed  it  for  that  purpose. 

Boas,  in  his  work  on  the  stomach  ^  describes  and  pictures 
an  intragastric  electrode  which  should  be  effective,  but  in- 
volves the  same  inconvenience  usually  experienced  in  washing 
out  the  stomach,  owing  to  the  prolonged  contact  of  a  tube  of 
considerable  size  with  the  throat  and  mouth. 

I  have  never  used  the  Stockton  electrode,  but  it  must  have 
distinct  advantages  for  cases  requiring  a  preliminary  lavage. 
Effect  of  Intragastric  Electricity  upon  Secretion. — My  ex- 
perience with  electricity  applied  within  the  stomach  has  been 
somewhat  striking  as  to  the  effects  on  secretion.  Besides 
finding  it  helpful  in  certain  cases  of  gastralgia,  and  in  some 
cases  of  obscure  gastric  pain  of  unknown  origin,  using  here 
the  positive  pole  of  the  galvanic  current  with  a  strength  of 
5  to  lo  ma.,  I  have  found  the  ordinary  faradic  current  in 
'  "  Diagnostik  u.  Therapie  der  Magenkrankheiten,"  I  Theil,  S.  298. 


Fig.  50. — Reed's  electrode. 


INTRAGASTRIC    METHODS   OF  TREATMENT  32$ 

virtually  all  cases  of  muscular  atony,  or  atonic  dilatation, 
decidedly  beneficial  and  sometimes  rapidly  curative.  The 
slowly  interrupted  current  of  any  faradic  coil  with  a  strength 
just  sufficient  to  produce  contractions  in  the  stomach,  and  the 
currents  obtainable  from  the  familiar  faradic  batteries  in 
general  use  having  coils  of  short,  coarse  wire  and  not  of  a  very 
high  power,  I  have  found  not  only  to  improve  the  motility  and 
gradually  to  contract  the  stomach,  when  it  was  enlarged,  but 
also,  as  a  rule,  to  stimulate  primarily  the  gasiric  glands  and 
increase  the  percentage  of  hydrochloric  acid,  in  those  cases  at 
least  in  which  the  latter  was  below  the  normal  without  atrophy 
having  developed. 

Except  in  a  single  case  reported  below,  I  have  never  em- 
ployed this  form  of  faradic  battery  in  hyperchlorhydria,  con- 
sidering its  effect  as  generally  tonic  and  stimulating.  I  be- 
lieve that  it  always  tends  to  stimulate  at  first  and  that,  just 
as  very  large  doses  of  drugs  can  overstimulate  and  depress, 
and  moderate  doses  frecjuently  repeated  often  do  the  same,  so 
a  very  powerful  faradic  current  for  a  short  time,  or  even  a  mild 
:one  daily  applied  for  a  long  time  (as  in  Case  I),  can  and  does 
produce  depression  of  the  glandular  function.  Doubtless 
there  is  no  possible  dose  of  faradism  which  could  rapidly  de- 
press the  motor  function  also,  since  the  primary  effect  of  even 
the  strongest  current  is  to  produce  a  tetanic  cramp  of  the 
muscle.'  There  is  the  probable  danger,  however,  that  a  too 
long  continuance  of  moderate  currents,  directly  applied  to  the 
stomach-walls,  would  in  the  end  by  over-stimulation  lower  the 
motor  function. 

With  a  good  high-tension  coil  it  is  possible  to  apply  a  much 
stronger  current  painlessly  than  with  the  ordinary  coil,  and 
too  strong  a  current  may  at  first  cause  increased  secretion  as 
I  is  the  case  with  the  ordinary  faradic  current. 

My  experience  teaches  that  such  a  coil  with  a  long  fine  wire 
and  rapid  interruptions  applied  with  one  pole  in  the  stomach 
and  the  other  in  the  form  of  a  large  flat  sponge,  felt,  or 
clay  electrode,   over  the  epigastrium,   will  generally,   with   a 


326  METHODS  OF  TREATMENT 

proper  strength  of  current  lessen  the  percentage  of  the  hydro- 
chloric acid  in  the  gastric  juice,  whether  it  was  previously 
normal  or  in  excess.  In  only  a  few  exceptional  cases  has  it 
failed  to  do  this,  and  then  the  treatment  was  not  kept  up 
with  sufficient  regularity,  nor  were  the  patients  under  the 
requisite  hygienic  conditions.  Having  early  learned  of  its 
markedly  depressing  effect  upon  the  glands,  I  have  never  em- 
ployed the  high-tension  coil  in  a  case  of  deficient  gastric 
secretion,  but  have  resorted  to  it  often  in  stubborn  cases  of 
the  opposite  class,  in  which  there  is  excessive  secretion — hyper- 
chlorhydria. 

Action  of  Faradic  Currents  on  Secretion  Discovered  Ac- 
cidentally.— My  discovery  of  this  power  in  faradic  currents  of 
high  intensity  was  accidental.  While  in  general  practice  I  had 
come  to  make  considerable  use  of  such  currents  in  ovarian  pain 
and  other  conditions  accompanied  by  obscure  pain  or  dis- 
comfort in  the  pelvis.  For  this  purpose  I  had  obtained  one  of 
Kidder's  best  high-tension  faradic  batteries  and,  after  replac- 
ing its  troublesome  chy  cells  b}-^  an  efficient  Grenet  cell,  found 
it  a  most  useful  machine.  When  I  began  to  make  a  large  use 
of  electricity  in  the  stomach,  this  particular  battery  proved  to 
be  the  most  convenient  and  reliable  one  in  my  outfit,  and  so 
was  most  frecjuenth^  employed.  I  was  soon  surprised  to  observe 
a  rapid  diminution  in  the  proportion  of  hydrochloric  acid  in 
the  stomach-contents  of  cases  thus  treated. 

REPORTS   OF   TWO   ILLUSTRATIVE    CASES. 

You  may  be  interested  in  the  reports  of  two  cases  which 
illustrate  strongly  the  depressing  influence  of  the  high-tension 
faradic  currents  upon  the  gastric  secretion.  Very  many  other 
similar  cases  are  recorded  in  my  notebooks,  though  at  present 
I  do  not  employ  the  method  so  often  as  formerly  for  the 
reason  that,  with  a  more  skillful  use  of  antacid  and  sedative 
remedies,  the  dernier  ressorf,  intragastric  electricity,,  is  less 
frequently  necessary.     Numerous  cases  which  involved  motor 


INTRAGASTRIC    METHODS   OF   TREATMENT  32/ 

onditions  with  or  without  dilatation  have  been  reported  by  me 
[n  previous  papers/ 

The  first  case  which  was  treated  by  me  with  the  help  of 
Intragastric  electricity  has  been  referred  to  briefly  in  a  previous 
)aper,'  but  shows  so  strikingly  the  great  value  of  this  method 
n  even  a  ver}^  desperate  condition,  that  a  fuller  account  of  it 
s  now  given  you: 

Case  I.  Lady,  aged  twenty-two  years,  unmarried,  was  sent 
jo  me  from  a  town  in  Northern  New  York  in  the  year  1896, 
vhile  I  was  in  general  practice  in  Atlantic  City.  She  had  been 
I'or  years  out  of  health  in  various  ways.  When  she  came  under 
;ny  care  she  had  dilatation  of  the  stomach  with  some  gas- 
■  roptosis,  very  movable  right  kidney,  and  catarrh  of  the  whole 
i  ^astro-intestinal  tract,  with  extreme  emaciation,  prostration, 
(ind  anaemia.  There  was  excess  of  the  gastric  secretion,  the 
r'ree  HCl  being  .182,  and  the  total  acidity  90.  The  lower 
30undary  of  the  stomach  was  three  inches  below  the  umbilicus. 
The  upper  boundary  was  only  one  inch  above  the  lowest  rib  in 
;he  left  parasternal  line.  She  was  barely  able  to  walk  and  was 
daily  growing  weaker  as  well  as  thinner.  There  was  also  a 
rise  of  temperature  to  ioo°"  or  higher,  every  afternoon.  I  put 
'ler  to  bed,  ordered  lavage  and  a  very  restricted  diet  w^th  some 
rectal  feeding,  after  irrigation  of  the  colon.  Tonic  medicines 
were  also  administered  per  rectum.  In  spite  of  all  this  the 
improvement  w-as  slight,  and  after  a  time  a  moderate  faradic 
current  from  an  ordinary  cheap  coarse  coil  was  applied  every 
day  with  one  electrode  in  the  stomach  and  the  other  over  the 
epigastrium.  To  avoid  fatiguing  the  patient  too  much,  the 
electricity  was  administered  not  directly  after  washing  out  the 
stomach,  but  at  another  time  of  the  day.  These  various  meas- 
ures, except  the  rest  in  bed,  were  continued  more  or  less  per- 
sistently during  a  period  of  three  months,  after  which  the  appli- 
cations of  electricity  were  made  every  second  day.  By  the  end 
of  tlie  three  months  the  stomach  had  decidedly  retracted  in  size, 

'Dilatation  of  the  Stomach,  with  Reports  of  Cases  Treated  by  Diet, 
Massage,  and  Intragastric  Electricity,  y^z^rwa/  American  Medical  Asso- 
ciation, July  30,  1898  ;  and  Displacements  and  Dilatations  of  the  Adomi- 
nal  Organs  ;  their  Relation  to  Faulty  Modes  of  Dress,  and  Their  Treat- 
ment, Therapeutic  Gazette,  September,  1899. 

^  "  International  Clinics,"  vol.  i. ,  Seventh  Series. 


328  METHODS    OF    TREATMENT  ■*! 

the  lower  border  being  then  found  one  inch  above  the  umbihcus. 
The  patient  had  gained  many  pounds  in  weight,  was  much 
stronger,  and  the  proportion  of  HCl  had  steadily  lessened.  An 
examination  of  the  stomach-contents  made  about  ten  weeks 
later  showed  an  absence  of  free  HCl  and  a  total  acidity  of  only 
35 ;  her  improvement  continued.  Two  years  after  my  treat- 
ment began,  though  she  had  meanwhile  returned  home  and  re- 
ported to.  me  at  long  intervals  only,  I  found  her  with  a  good 
color,  plump  and  strong.  Her  digestion  was  reasonably  good 
with  moderate  care  of  her  diet.  The  former  loose  kidney 
could  no  longer  be  felt,  and  her  stomach  had  not  only  retracted 
within  the  noniial  limits,  but  had  returned  to  its  normal  posi- 
tion. 

The  foregoing  having  been  the  first  case  in  which  I  ap- 
plied any  form  of  the  electric  current  within  the  stomach,  I 
was  inexperienced,  and  thought  only  of  the  very  serious  con- 
dition of  dilatation  and  stagnation,  with  the  resulting  alarm- 
ing failure  of  nutrition.  I  had  then  had  a  limited  experience 
only  with  hyperchlorhydria,  and  did  not  realize  that  this  con- 
dition, by  producing  a  spasmodic  closure  of  the  pylorus,  had 
doubtless  been  the  chief  cause  of  the  dilatation.  In  making 
the  direct  electric  applications  to  the.  stomach,  I  looked  upon 
them  as  an  extreme  measure  for  combating  the  dangerous 
motor  condition  and  did  not  consider  the  effect  upon  secre- 
tion. Therefore,  frequent  tests  of  the  stomach-contents  were 
not  made  as  is  my  present  custom  in  all  such  cases,  else  the 
percentage  of  HCl  would  not  have  been  allowed  to  be  lowered 
so  far.  But  with  the  administration  of  hydrochloric  acid  and 
pepsin  as  medicines,  and  later  tonics  by  the  mouth,  the  gastric 
juice  soon  regained  its  normal  strength. 

The  patient  above  referred  to  brought  an  invalid  mother  to 
consult  me  in  August,  1903,  and  was  herself  then  in  good 
health,  ceven  years  after  the  treatment  described,  having 
gained  fully  forty  pounds  in  weight. 

Case  H.  Widow,  aged  thirty-five,  long  neurasthenic  and 
dyspeptic.  Right  kidney  very  movable.  Stomach  somewhat 
dilated ;  constipation  and  some  intestinal  catarrh.     Percentage 


INTRAGASTRIC    METHODS   OF   TREATMENT  329 

of  HCl  in  gastric  juice  excessive  when  patient  first  came  under 
my  care  in  1897.  The  hyperchlorhydria  was  then  soon 
controlled  by  the  usual  remedies,  and  with  it  most  of  her  com- 
plaints disappeared.  But  there  have  been  recurrences  since, 
due  probably  to  reflex  irritation  from  the  floating  kidney.  In 
]\Iarch,  1899,  she  returned  with  the  HCl  in  greater  excess  than 
ever  before,  and  this  time  persistent  treatment  by  diet,  alkalies, 
belladonna,  etc.,  failed  to  control  it.  Finally  the  high-tension 
faradic  current  was  applied  through  my  intragastric  electrode 
six  times  at  inters-als  of  two  to  three  days,  with  the  result  that 
the  percentage  of  HCl  came  down  to  .051.  It  had  been  as 
high  as  .196  after  the  Ewald  test-breakfast.  I  urged  opera- 
tion, which  the  patient  declined.  In  September  last  she  re- 
turned with  marked  hyperchlorhydria  again,  and  besides, 
whene^'er  we  tested  her  stomach-contents,  bile  was  always 
found  present,  showing  probably  pressure  by  the  kidney  on  the 
duodenum  below  the  point  of  entrance  of  the  common  bile- 
duct.  She  had  lost  much  flesh  and  her  color  was  very  sallow. 
Again  I  tried  to  relieve  her  by  means  of  diet  and  full  doses  of 
the  usual  remedies  and,  again  failing,  applied  the  high-tension 
current  within  the  stomach  in  addition  to  the  administration 
of  the  remedies  internally.  Again  there  was  a  prompt  diminu- 
tion of  the  HCl  secretion  to  the  normal. 

The  Technique  of  Applying  Electricity  Intragastrically. — 
A  few  words  more  as  to  the  technique  of  this  method  of  ad- 
ministering electricity.     My  patients  after  a  light,  early  break- 
fast come  for  this  treatment  not  earlier  than  11  a.  m.,  and  those 
with  very  sensitive  stomachs  and  poor  motility,  preferably  at 
12  or  later.     One  or  two  glasses  of  water,  according  to  the 
capacity  of  the  stomach,  are  then  taken  and  a  large  flat  elec- 
trode, well-wetted,   applied   over  the   epigastrium.     In   some 
cases,  when,  as  often  happens  in  these  cases,  the  lower  four  or 
I  five  dorsal  vertebrae  are  sensitive,  the  flat  electrode  is  applied 
I  over  them.     Then  the  battery  being  ready,  the  patient,  while 
I  sitting  on  the  side  of  a  lounge  or  couch,  swallows  the  intra- 
gastric electrode  with  a  little  guidance  and  gentle  pushing,  if 
^'  necessary,  on  the  part  of  the  physician,  and  afterwards  lies 

idown.  The  current  is  turned  on  gently  at  first  and  the 
strength    gradually    increased    to    that     which     the    patient 


330  METHODS    OF    TREATMENT 

can  distinctly  feel,  not  all  that  he  can  possibly  bear,  since  the 
maximum  current  which  can  be  borne  is  very  much  stronger 
with  a  high-tension  coil  than  with  an  ordinary  faradic 
battery. 

Five  minutes  of  such  a  current  every  other  day,  I  have 
found  enough  as  a  laile,  though  in  stubborn  cases  it  is  given 
for  seven  or  eight  minutes  at  each  sitting.  More  has  some- 
times produced  harmful  depression  with  loss  of  appetite, 
and  after  twelve  or  fifteen  such  treatments,  if  the  desired 
result  has  not  been  sooner  accomplished,  it  is  best  to  in- 
termit them  for  a  week  or  two.  It  needs  to  be  strongly  em- 
phasized, however,  that  in  all  cases  in  which  electricity  is 
applied  within  the  stomach,  especially  in  those  in  which  there 
is  hydrochloric  acid  excess  for  which  a  high-tension  current  is 
being  used,  there  should  be  a  quantitative  test  of  the  stomach- 
contents  about  every  week,  or,  at  the  longest,  every  two  weeks, 
to  prevent  the  risk  of  injurious  overaction. 

A  very  few  patients  will  be  seen  in  whom  no  kind  of  intra- 
gastric instrument  can  be  used  without  a  harmful  amount  of 
disturbance.  But  the  electrode  employed  by  me  is  more  easily 
introduced  than  the  ordinary  stomach  tube  and,  once  in  posi- 
tion, rarely  occasions  any  considerable  annoyance.  The  ex- 
ceptions are  comprised  by  a  small  proportion  of  cases  in  which 
nausea  is  experienced  when  the  current  strength  is  increased 
beyond  a  certain  moderate  limit.  In  these  a  milder  current 
needs  to  be  used,  and  a  longer  course  of  treatment  is  therefore 
required  to  effect  the  desired  result. 

A  longer  experience  with  this  form  of  treatment  has  resulted 
in  more  failures  than  at  first,  but  I  am  now  convinced  that  these 
were  generally  due  to  the  presence  of  a  latent  ulcer  in  either  the 
stomach  or  duodenum.  Later  reports  from  the  surgeons  con- 
cerning the  findings  at  operations  have  shown  frequently  ulcers 
in  the  duodenum  especially,  with  no  symptoms  other  than  those 
of  hyperchlorhydria. 


LECTURE   XXXI 

THE    MEDICINAL  THERAPY  OF  DISEASES 
OF  THE  STOMACH  AND  INTESTINES 

In  placing  this  form  of  therapy  last,  I  do  not  intend  to  con- 
vey to  you  the  impression  that  it  is  of  slight  importance,  but 
rather  that  in  the  treatment  of  the  chronic  affections  of  the 
stomach  and  intestines  as  well  as  of  most  chronic  diseases, — 
it  is  less  frecjuently  of  permanent  advantage  tO'  the  patient 
than  the  hygienic,  dietetic,  and  mechanical  methods  already 
described.  In  many  forms  of  gastro-intestinal  diseases, 
particularly  in  gastric  ulcer,  and  all  the  derangements 
associated  with  marked  hypersecretion  of  the  HCl  of  the  gas- 
tric juice,  diarrhea,  intestinal  colic,  etc.,  certain  drugs  can 
prove  extremely  efficacious,  especially  in  the  beginning  of  the 
treatment.  I  shall  not  attempt  here  to  specify  all  the  drugs 
which  may  be  useful  in  treating  gastro-intestinal  diseases,  but 
rather  to  refer  to  the  various  classes  of  remedies,  specifying 
particularly  such  of  them  as  I  have  found  in  my  own  experi- 
ence to  possess  marked  remedial  value.  For  the  purposes  of 
this  discussion,  drugs  may  be  classified  into  acids  and  alkalies, 
(ligestants,  astringents,  antiseptics,  stimulants  and  sedatives, 
nerve  tonics,  chalybeates,  certain  bland  oils  and  drugs  of  the 
bismuth  type  which,  in  addition  to  their  general  systemic 
effects,  produce  mechanically,  by  their  local  sedative  action,  a 
remedial  influence  ;  and  laxatives  or  purgatives. 

The  Administrations  of  Acids. — HCl  is  virtually  the  only 
acid  which  I  have  found  it  necessary  to  prescribe  as  an  acid 
in  real  gastric  or  intestinal  cases,  though  in  nervous  dyspepsia 
from  neurasthenia  dilute  phosphoric  acid  is  often  an  efficient 
substitute.     Salicylic,  carbolic,  and  hydrocyanic  acids  are  also 


332  METHODS    OF    TREATMENT 

occasionally  useful,  but  none  of  these  act  as  acids,  being 
prescribed  on  account  of  other  properties  in  them.  Nitric  and 
nitrohydrochloric  acids  are  often  given  in  gastric  and  hepatic 
cases  and  the  latter  I  formerly  employed  largely  myself,  but 
we  possess  very  much  less  definite  knowledge  of  their  effects, 
and  I  doubt  whether  either  is  so  well  suited  to  atonic  gastric 
conditions  as  the  dilute  hydrochloric  acid.  Letting  the  latter, 
therefore,  stand  for  the  whole  class  of  acids,  when  such  a 
remedy  is  needed  in  the  varieties  of  disease  under  discussion, 
I  cannot  do  better  than  to  reproduce  here  in  full  the  following 
paper  by  myself,  which  was  presented  to  the  Section  of  Materia 
Medica  and  Therapeutics  of  the  American  Medical  Association 
in  June,  1898.     The  paper  was  as  follows: 

"  The  Place  of  Hydrochloric  Acid  in  the  Treatment  of 
Diseases  of  the  Stomach. — The  time  has  come  for  a  definite 
and  precise  statement  of  what  hydrochloric  acid  can  do  in  the 
treatment  of  stomach  diseases — when  and  how  it  is  useful,  as 
well  as  when  and  how  it  can  be  harmful. 

"  Riegel  in  his  recent  work  ^  very  pertinently  remarks : 
'  While  formerly  HCl  was  prescribed  in  nearly  all  dyspeptic 
conditions,  its  employment  has  of  late  been  essentially  limited, 
since  it  has  been  recognized  that  it  is  by  no  means  true,  as  was 
once  assumed,  that  in  almost  every  form  of  dyspepsia  a  lack 
of  HCl  exists.'  There  is  much  other  testimony  to  the  effect 
that  even  among  the  aggravated  stomach  conditions  for  which 
the  advice  of  a  specialist  is  sought,  an  excess  of  this  acid  is 
very  often  found  in  the  gastric  juice.  Could  all  cases  of 
gastric  derangement,  including  the  earlier  stages  of  catarrhal 
affections,  be  brought  to  the  test  of  a  chemical  analysis  of  the 
stomach  contents,  it  is  probable  that  those  with  either  a  normal 
or  excessive  secretion  would  be  largely  in  the  majority.  And 
none  of  these  require  the  administration  of  HCl  as  a  medicine. 
Indeed,  it  is  capable  of  doing  pronounced  harm  in  all  such 
cases.  We  should  expect,  a  priori,  that  to  introduce  this  active 
drug  artificially  into  stomachs  which  already  secrete  it  in  too 
1  "  Die  Erkrankungen  des  Magens,"  Vienna,  1896. 


MEDICINAL   THERAPY    OF   DISEASES    OF    STOMACH  333 

large  quantities,  would  intensify  the  depressing  and  painful- 
symptoms  of  hyperchlorhydria.     Experience  has  abundantly 
shown  that  this  result  usually  follows  in  such  cases  when  the 
jdrug  is  administered  in  considerable  doses. 
j     "  The  well-known  antiseptic  power  of  HCl  might  tempt  one 
to  give  it  in  the  numerous  cases  in  which,  despite  the  presence 
pf  a  normal  percentage  of  this  acid  in  the  gastric  juice,  the 
[patients  suffer  from  eructations  of  gas  as  a  result  of  fermenta- 
!:ion  in  the  stomach,  and  (as  still  more  frequently  happens  in 
:ases  with   a   normal   or   overabundant    secretion   of   gastric 
nice)  are  plagued  with  a  large  amount  of  intestinal  flatulency, 
[ndeed,  this  remedy  is  administered  every  day  by  excellent 
i  physicians    in    these    conditions,    not    after    having    actually 
earned,  through  a  gastric  analysis,  that  a  full  proportion  of 
:\1CI  is  not  secreted,  but  upon  a  venture,  assuming  that  there 
rnay  be  a  deficiency,  and  if  not,  that  in  any  case  the  drug  is 
,  Imtiseptic  and  must  do  some  good.     Just  here  is  where  the 
nistake  is  made. 

Hydrochloric    Acid    is    an    Injurious    Remedy    in    Certain 

;)ases. — "  To  administer  HCl  in  cases  in  which  it  is  not  defi- 

ient,  is  not  only  to  do  no  possible  good,  but  generally  to  do 

;iarm,  and  for  these  reasons :  This  drug,  as  has  been  pointed  out 

,y  the  writer  in  previous  papers,^  acts  even  in  small  doses  as  a 

ecided  stimulant  to  the  gastric  glands,  and  when  long  con- 

linued  rarely  fails  to  increase  largely  their  activity,  except  in 

astric  atrophy  or  cancer.     This  property,  which  renders  it  so 

seful  as  a   remedy   when   the  gastric  juice   is   insufficiently 

;creted,  becomes  a  cause  of  injury  in  the  opposite  condition. 

fherefore,  HCl  taken  into  a  stomach  already  fully  supplied 

'■ith  it,  and  the  stomach  contents  after  meals  being  thus  as 

:id  as  nature  intended  them  to  be,  must  not  only  produce  at 

le  time  an  excessive  degree  of  acidity,  with  all  the  harmful 

'Diet  in  the  Chronic  Catarrhs  of  the  Gastro-Intestinal  TvRct,  Jotrr. 
»ier.  Med.  Assoc,  February  19,  1898  ;  and  Important  Indications  and 
intra-Indications  for  Massage  of  the  Abdomen,  Inter.  Med.  Ma^.,]an-a- 
y,  1898. 


334  METHODS    OF    TREATMENT 

results  especially  to  digestion  in  the  small  intestine  which  this 
implies,  hut,  if  administered  often  enough,  may  easily  set  up  a 
more  or  less  permanent  hyperchlorhydria. 

Hydrochloric  Acid  does  not  Prevent  Fermentation. — "  But 
it  may  be  urged  that  we  might  risk  some  overacidifying  of  the 
gastric  juice  and  the  resulting  impairment  of  intestinal  diges- 
tion if  by  this  means  we  can  lessen  fermentation  in  the  stomach. 
Unfortunately,  however,  in  the  cases  in  which  there  is  no 
deficiency  of  HCl,  very  little,  if  any,  antiseptic  action  can  be 
demonstrated  as  a  result  of  its  administration.  In  the  acid 
gastritis  described  by  various  authors  in  Germany  and  France, 
and  especially  in  recent  treatises  by  Hemm^ter  ^  and  by  Van 
Valzah  and  Xisbet  ■  in  this  country,  a  condition  which  my  own 
experience  has  shown  to  be  very  common,  and  the  one  most 
often  present  when  a  normal  or  excessive  proportion  of  HCl 
is  found  associated  with  much  fermentation,  the  gas-forming 
bacteria  seem  to  acquire  a  tolerance  for  the  HCl  and  to  thrive 
in  spite  of  it.  At  all  events,  the  fact  that  even  a  very  great 
excess  of  HCl  in  the  human  stomach  does  not  prevent  fer- 
mentation has  been  made  familiar  to  the  writer  by  a  large 
number  of  observations.  Riegel  has  lately  called  attention  to  it 
without  attempting  to  account  for  it.  In  his  work  already 
referred  to  he  says : 

"  '  That  the  presence  of  free  HCl  in  the  stomach  contents  is  no 
hindrance  to  the  de\'elopment  of  an  abundant  gaseous  fermenta- 
tion is  a  long  since  established  clinical  fact,  which,  through 
the  researches  of  Kuhn  and  Strauss,  has  been  given  a  further 
support.  It  has  been  proved  that  the  HCl  of  the  gastric  juice 
under  the  existing  conditions  has  absolutely  not  the  disinfecting 
properties  against  the  yeast  fungi  which  have  been  established 
for  it  in  a  pure  solution  of  the  drug  or  in  artificially  prepared 
gastric  juice,  but,  on  the  contrary,  the  view  always  maintained 

1  "  Diseases  of  the  Stomach,"  by  Dr.  John  C.  Hemmeter,  Philadelphia, 

2  "  Diseases  of  the  Stomach,"  by  Dr.  W.  W.  Van  Valzah  and  Dr.  J.  B. 
Nisbet,  Philadelphia,  1898. 


MEDICINAL    THERAPY    OF    DISEASES    OF    STOMACH  335 

by  US  has  been  confirmed — that  when  stagnation  exists  the 
preferred  soil  for  the  gaseous  fermentation  is  afforded  by  just 
those  cases  which   show   a  normal   or  overlarge  amount   of 
*  HCl.' 

"  Some  experiments  recently  reported  to  the  Hospital  ]\Iedi- 
cal  Society  by  Toinot  and  Brouardel,  and  published  in  the 
I  British  Medical  Journal,  show-  that  the  bacillus  coli  can  be 
I  made  to  acquire  a  tolerance  for  arsenious  acid  even  in  strong 
!  solutions.  They  succeeded  in  training  this  bacillus  to  grow 
well  in  bouillon  containing  three  grams  to  the  liter  of  arsenious 
jj  acid. 

"  Then,  why  may  it  not  be  that  bacteria  in  the  stomach  grad- 
ually become  accustomed  to  the  presence  of  HCl  until  finally 
even  a  large  excess  of  it  does  not  affect  them?    At  all  events 
the  gas-forming  micro-organisms  are  found  to  flourish  in  the 
I  stomach  even  when  there  is  present  a  very  large  excess  of 
HCl ;  and  in  these  cases  when  they  have  become  ciironic,  it  is 
[i  the  rule  to  have  grievous  complaints  of  flatulency,  both  gastric 
'  and  intestinal,  with  an  endless  train  of  nervous  symptoms, 
'  including,  especially,  mental  depression  and  insomnia,  along 
with,  usually,  constipation. 

|,      Valuable  Effects  of  Hydrochloric  Acid. — "  AVhat  has  already 
I  been  said  as  to  the  contra-indications  for  HCl  tells,  in  a  meas- 
ure, where  and  how  it  can  be  helpful  in  the  treatment  of  gastric 
I  affections.   There  are  a  few  prominent  gastro-enterologists  who 
;:  seem  to  place  little  reliance  upon  this  drug  in  any  case,  but  the 
i  writer  has  found  it  of  exceeding  value  not  only  as  a  palliative 
in  cases  of  atonic  dyspepsia,  but  also  as  a  reconstructive  tonic 
in  cases  of  chronic  gastric  catarrh,  which  have  not  yet  pro- 
gressed to  entire  atrophy  of  the  glands.     In  fact,  the  results 
which  have  followed  its  administration  in  my  practice  (usually 
in  combination  with  pepsin)  fully  warrant  me  in  assigning  to 
it  in  the  therapeutics  of  all  the  stomach  diseases  characterized 
by  hypoi^epsia  (except  cancer  and  atrophy)  a  place  second  only 
to  diet   and  the  mechanical  treatments,   including  especially 
abdominal  massage. 


33^  METHODS    OF    TREATMENT      ' 

"  My  notebooks  contain  the  histories  of  a  large  number  of 
cases  in  which  the  administration  of  HCl  for  from  one  to  four 
months,  more  or  less  continuously,  has  been  followed  by  a 
most  notable  and  apparently  permanent  increase  in  the  secre- 
tion of  the  gastric  glands.  In  the  majority  of  my  cases  mas- 
sage and  the  use  of  pulleys  or  other  suitable  exercise  for  the 
strengthening  of  the  trunk  muscles  were  also  employed  as  a 
regular  part  of  the  treatment,  and  the  results  in  these  cannot, 
of  course,  be  cited  as  proving  the  efficacy  of  any  one  of  the 
curative  measures  relied  upon.  The  cure  of  the  patient  having 
been  naturally  the  first  consideration,  the  treatment  has  not 
been  limited  to  any  one  agency,  no  matter  how  valuable.  A 
large  amount  of  evidence  has  thus  been  accumulated  which, 
it  must  be  admitted,  is  inconclusive  in  so  far  as  concerns  the 
relative  value  of  the  various  remedies  used. 

"  But,  fortunately  for  the  purposes  of  this  paper,  some  of  my 
hypopeptic  patients  found  it  impracticable  to  have  massage, 
and,  at  the  same  time,  were  unable,  for  various  reasons,  to 
carry  out  with  any  regularity  the  directions  as  to  methodical 
exercise,  and  the  marked  gain  in  digestive  power  acquired  by 
these  must  be  credited  mainly  to  the  medicine  taken. 

"  AA'egele^  and  Hemmeter-  among  recent  authors  bear  wit- 
ness to  the  powers  of  HCl  as  a  stomachic  or  stimulant  to  the 
peptic  glands.  Hemmeter  also  quotes  Riegel,  Reichmann,  -and 
]\lintz  as  having  reported  cases  of  achylia  gastrica  in  which 
the  restoration  of  the  secretion  of  HCl  was  efifected  by  a  more 
or  less  prolonged  dosage  with  the  same  acid.  Hemmeter  gives 
twenty  drops  of  the  diluted  HCl  in  appropriate  cases  in  two 
ounces  of  water  every  half  hour,  beginning  fifteen  minutes 
before  meals  and  continuing  it  till  half  an  hour  after  the  meal. 
He  has  frequently  seen  excellent  results  from  this  method,  and 
Ijelieves  that  the  motor  function  of  the  stomach  is  favorably 
influenced  as  well  as  the  glands,  a  view  which  my  own  experi- 

■■  "  Therapie  der  Verdauungskrankheiten,"  von  Dr.  Carl  Wegele,  Janu- 
ary, 1895. 
«  Loc.  cit. 


MEDICINAL    THERAPY    OF    DISEASES    OF    STOMACH  337 

ence  confirms.  My  practice  has  been  to  give  much  smaller 
doses,  I  direct  the  patient  usually  to  begin  with  a  dose  of  four 
or  five  drops  of  the  dilute  HCl  given  after  each  meal  in  this 
way:  The  amount  prescribed,  which  is  gradually  increased  if 
necessary  up  to  ten,  or  exceptionally  even  to  twenty  drops,  is 
added  to  half  a  goblet  of  water  which  the  patient  is  directed 
to  take  in  small  sips  at  frequent  intervals  during  an  hour  or 
an  hour  and  a  half.  In  cases  of  complete  or  nearly  complete 
anacidity  the  sipping  of  the  diluted  acid  is  begun  immediately 
after  the  meal,  but  in  other  cases  not  till  the  meal  has  been  over 
for  half  an  hour.  In  this  way  the  amylaceous  portions  of  the 
food  are  given  time  for  the  action  of  the  saliva.  I  was  led  to 
adopt  this  gradual  method  of  administering  the  acid  through 
having  observed  a  number  of  cases  with  absence  of  free  HCl 
in  which  the  patients  complained  of  a  marked  burning  in  their 
stomachs  after  taking  quite  small  doses  of  the  remedy.  This 
apparent  intolerance  of  the  drug  was  overcome  entirely  by 
having  it  taken  gradually  in  small  sips,  and  the  results  eventu- 
ally were  quite  as  gratifying  as  in  other  cases  in  which  no  such 
disagreement  had  occurred. 

"  Except  in  those  cases  where,  in  spite  of  deficient  or  absent 
HCl  secretion,  there  had  been  demonstrated  a  normal  propor- 
tion of  pepsin  or  of  pepsinogen,  I  have  usually  combined  with 
HCl  a  moderate  amount  of  a  good  preparation  of  pepsin  in  the 
form  of  a  glycerole.  When,  owing  to  the  exigencies  of  a  busy 
practice,  the  quantitative  tests  have  included  the  total  acidity 
and  the  amount  of  free  HCl  only,  pepsin  has  generally  been 
added  to  the  mixture,  and  in  a  very  large  proportion  of  such 
cases  the  digestive  power  has  decidedly  increased,  insomuch 
that  the  patients  after  a  time  were  able  to  do  without  stomach 
remedies. 

"  Reports  of  Cases. — In  the  cases,  reports  of  which  are  given 
below,  no  very  severe  restrictions  of  the  diet  were  imposed, 
though  hot  or  fresh  bread,  fried  articles,  sugar,  nuts,  vinegar, 
the  sourer  fruits,  especially  uncooked,  and  shellfish,  except 
oysters   in  their  season,  were  excluded,  and  the  patients  were 


33S  METHODS    OF    TREATMENT 

enjoined  to  eat  slowly,  using  their  saliva  to  moisten  all 
starch  foods  and  to  drink  either  nothing  or  very  sparingly 
aP  meals. 

"  Case  I. — Lady,  aged  36,  resident  in  New  York,  while  on 
a  visit  in  Philadelphia,  came  under  my  care  on  account  of 
chronic  indigestion,  with  much  fermentation,  constipation, 
anaemia,  irregular  menses,  impaired  sleep,  and  cardiac  palpi- 
tation. She  gave  a  history  of  having  suffered  in  a  similar 
manner  for  several  years,  and  of  having  had  more  or  less, 
trouble  with  her  stomach  for  twelve  years.  Had  formerly  had 
much  pain  after  meals,  and  for  this  had  been  directed  to  take, 
freely  and  continuously,  tablets  made  up  mostly  of  sodium 
bicarbonate,  about  five  grains  in  each.  She  began  by  taking 
one  every  hour,  or  sixteen  a  day,  but  finally  reduced  them  to 
eight  daily.  These  were  continued  with  little  or  no  medical 
oversight  for  three  years,  until  they  markedly  disagreed  by 
causing  nausea.  External  examination,  when  this  patient  came 
under  my  care  in  December,  1896,  showed  the  right  kidney  to 
be  loose  and  very  movable  and  the  stomach  dilated,  extending 
from  the  normal  limit  above  to  several  inches  below  the  level 
of  the  umbilicus,  with  tardy  expulsion  of  the  contents.  The 
liver  area  was  somewhat  smaller  than  normal,  but  the  other 
organs  presented  nothing  abnormal. 

"  Analysis  of  the  stomach  contents  after  a  test  breakfast 
showed  a  total  acidity  of  only  24  and  an  entire  absence  of  free 
HCl.  Rennet  test,  no  result  in  twelve  hours.  Indican  in 
excess  in  urine.  My  first  prescription  contained  in  each  fluid 
dram  in  x  of  dilute  HCl  with  111  xv  of  glycerole  of  pepsin, 
m  i^  of  Tr.  Nuc.  vom.  and  111  ^  of  carbolic  acid.  A  tea- 
spoonful  was  added  to  half  a  glass  of  water  and,  beginning 
half  an  hour  after  meals,  the  patient  sipped  the  entire  solution 
during  the  hour  following. 

"  Shortly  after  l^eginning  treatment  she  was  attacked  with  a 
severe  diarrhea,  which  necessitated  a  different  line  of  medica- 
tion for  a  week  or  more.  Then  a  new  digestive  mixture  was 
given,  with  the  dose  of  HCl  reduced  one-half,  and  the  other 
ingredients,  except  pepsin,  omitted. 

"  February  25,  1897,  the  patient  came  on  from  New  York 
and  reported  improvement  in  nearly  all  ways.  She  had  con- 
tinued her  last  mixture.  The  stomach  analysis  now  showed 
T.  A.  40  and  free  HCl  .0146.     Less  fermentation  and  better 


MEDICINAL    THERAPY    OF    DISEASES    OF    STOMACH  339 

sleep.  No  excess  of  inclican  in  urine.  The  pepsin  was  now 
left  out  of  the  HCl  mixture  and  a  few  drops  of  carbolic  acid 
were  again  added  to  it.  Massage  of  the  abdomen  was  tried, 
but  proved  too  exciting  to  the  menstrual  function,  the  first- 
treatment  having  brought  on  the  flow,  out  of  time  and  in 
excess. 

"  Since  the  above  date,  the  patient  has  seen  me  at  long  inter- 
vals only.  October  7,  1897,  she  came  on  to  Philadelphia  and 
reported  that  she  had  continued  the  HCl  mixture  until  six 
weeks  previously  and  considered  herself  then  practically  well. 
She  had  gained  twelve  pounds  in  weight,  presented  a  good 
color  and  clean  tongue,  and  had  lost  most  of  her  symptoms 
except  the  constipation. 

"  She  afterward  fell  ill  with  grippe  in  New  York,  and  came 
under  the  care  of  Dr.  Lockwood  of  that  city  011  account  of  this 
disease  and  its  complications.  She  was  confined  to  her  bed  or 
her  room  there  a  large  part  of  the  winter,  but  at  the  end  of  it 
all  her  physician  wrote  me,  under  date  of  March  28,  1898,  that 
a  gastric  analysis  showed  total  acidity  50;  free  HCl  22  (equal 
to  .080)  and  combined  HCl  22. 

"  She  reported  herself  to  me  again  April  4,  1898,  and  looked 
well,  considering  her  recent  long  illness.  There  was  improved 
gastric  motility,  but  her  stomach  was  still  greatly  enlarged, 
she  having  declined  intragastric  electricity  and  abdominal 
massage,  the  two  surest  remedies  for  that  condition. 

"  Case  H. — Lady,  aged  40,  wife  of  a  physician  in  a  neigh- 
boring city,  consulted  me  March  22,  1897,  on  account  of 
paroxysmal  attacks  of  indigestion,  from  which  she  had  suf- 
fered for  twenty-six  years.  They  were  characterized  by  vio- 
lent eructations  of  gas  and  seemed  to  be  caused  by  some  un- 
usual emotion  or  excitement.  Formerly  they  occurred  once  in 
several  months  and  were  not  followed  by  any  specially  unpleas- 
ant consequences,  except  nausea  and  some  feeling  of  oppres- 
sion. But  within  the  last  two  years  there  have  been  three 
serious  attacks  of  the  kind,  which  were  followed  by  colicky 
pains  and  jaundice,  with  pruritus,  lasting  a  week.  These 
attacks  also  followed  some  marked  nervous  shock  or  emotional 
excitement.  One  occurred  just  after  her  father's  death.  Be- 
tween times  she  is  said  to  have  had  usually  fair  digestion,  with 
no  ])ain  or  discomfort  after  meals  and  very  little  eructation. 
Her  bowels  have  l^een  fairlv  regular  as  a  rule,  but  she  is  very 
constipated  ahvays  at  the  time  of  the  attacks.     The  latter,  of 


340  METHODS    OF    TREATMENT 

late,  have  sometimes  recurred  every  day  for  several  weeks, 
accompanied  by  severe  colicky  pains  and  vomiting.  Ingesta, 
taken  two  or  three  days  before,  have  occasionally  been  vomited. 
Color  pale,  and  looks  dejected.  Physical  examination :  Lungs 
and  heart  normal.  Liver  enlarged.  Stomach,  slight  displace- 
ment downward  along  with  atonic  dilatation ;  the  upper  bound- 
ary was  one  to  one  and  a  half  inches  too  low,  and  the  lower 
boundary  between  two  and  three  inches  below  the  level  of  the 
umbilicus.  The  kidneys  not  palpable.  No  tumor.  Gastric 
analysis  after  test  breakfast :  T.  A.  12  ;  free  HCl  entirely  want- 
ing. Small  amount  of  mucus.  Diagnosis :  Chronic  catarrh 
of  the  stomach  and  duodenum.  Prescribed :-  3  Tr.  Nuc. 
vomic,  f  3ij;  Ac.  hydrochlor.  dil,  q.  s.  ad  f Sj ;  Sig.  10  to  15 
drops  in  half  a  glass  of  water  after  meals.  Diet  to  be  as  unfer- 
mentable  as  possible. 

"  Two  months  later  patient  reported  improvement.  No  fur- 
ther attacks. 

"  August  6th  of  same  year  her  husband  reported  that  she 
had  been  obliged  to  continue  the  mixture  regularly.  Every 
attempt  to  omit  it  was  followed  by  a  return  of  indigestion. 
October  14th;  patient  recovered  a  few  days  ago  from  one  of 
her  severe  attacks,  which  lasted  two  weeks,  with  eructations, 
pain,  and  constipation. 

"Gastric  analysis:  T.  A.  18;  free  HCl,  none;  mucus,  very 
small  amount.  Prescribed:  IJ  Ac.  hydrochlor.  dil.,  f  3  vj ;  gly- 
cerol pepsin,  q.  s.  ad  fjij  ;  Sig.  Ten  drops  in  half  a  glass  of 
water,  half  an  hour  after  meals,  by  sips.  Every  other  week 
to  take  the  following:  1^  Argent,  nitrat.,  gr.  x;  Ext.  tar- 
axaci,  3  j ;  M.  et.  ft.  pil  No.  LX. ;  Sig.  One  after  each 
meal. 

"April  21,  1898.  Has  taken  both  medicines,  as  above 
ordered,  the  HCl  mixture  continuously. and  the  silver  half  the 
time.  She  now  has  a  good  color  and  is  very  much  stronger. 
No  further  attacks.  Gastric  analysis :  T.  A.  40;  free  HCl  .041 
(nearly  normal)  ;  mucus,  a  small  amount.  The  lower  border 
of  the  stomach  was  found  to  be  near  the  level  of  the  umbili- 
icus. 

"  Case  HI. — Lady,  a  teacher,  aged  23,  referred  by  Dr. 
Samuel  Bolton  of  Philadelphia,  October  6,  1897.  Her  chief 
complaint  was  headaches  and  vomiting  every  few  days  with 
much  nausea,  and  occasionally  vomiting,  especially  evenings 
between  the  attacks.     There  was  also  stubborn  constipation 


MEDICINAL    THERAPY    OF    DISEASES    OF    STOMACH  34 1 

and  feeling  of  load  in  her  stomach  after  meals.  Organs  gen- 
erally found  healthy  except  stomach,  which  was  moderately 
dilated,  extending  down  to  half  an  inch  below  the  umbilicus 
with  delayed  emptying.  The  gastric  analysis  showed  only  a 
very  small  amount  of  free  HCl — .014,  though  the  total  acidity 
was  66,  representing  largely  fermentation  products.  There 
was  much  mucus  in  the  stomach.  I  advised  lavage  and  the 
combination  of  HCl  and  pepsin  as  the  main  treatment.  On 
account  of  marked  starch  indigestion,  she  also  took  Taka-dias- 
tase  for  a  time,  and  Roncegno  water  was  taken  for  some  weeks 
to  bring  up  the  cjuality  of  the  blood. 

"  On  April  9,  1898,  I  found  the  stomach  much  retracted  in 
size,  the  lower  border  being  one  and  a  half  inches  above  the 
umbilicus,  and  the  gastric  analysis  showed  T.  A.  56 ;  free  HCl 
.075  (that  is  a  normal  secretion)  ;  mucus  a  very  small  amount. 
She  had  had  no  severe  headache  with  vomiting  for  three 
months  and  had  regained  a  normal  color,  though  her  gastric 
catarrh  is  not  yet  entirely  well. 

"  Case  IV. — Gentleman,  aged  66,  consulted  me  July  21, 
1897,  ^^  Atlantic  City,  on  account  of  chronic  indigestion,  from 
which  he  claimed  to  have  suffered  nearly  all  his  life.  Painful 
accumulations  of  gas  and  obstinate  constipation  were  prom- 
inent features.  The  external  physical  examination  revealed 
nothing  abnormal.  Gastric  analysis:  T.  A.  16;  free  HCl 
wanting.  Starch  digestion  good.  Mucus  very  small  amount. 
He  was  placed  upon  H^Cl  and  pepsin  in  the  usual  way.  He 
has  since  seen  me  several  times  on  account  of  his  wife, 
but  reported  that  he  himself  was  doing  so  well  on  the  di- 
gestive mixture  as  not  to  require  any  further  medical  assist- 
ance. 

"  December  i6th,  he  was  seen,  and  was  then  feeling  well. 
On  April  22,  1898,  his  wife  called  to  consult  me  for  herself 
and  reported  that  her  husband  had  been  continuing  his  HCl 
and  pepsin,  though  less  regularly,  having  virtually  recovered 
his  health.  He  had  taken  no  other  medicine  except  a  little  nux 
vomica  during  the  first  few  weeks,  and  a  laxative  at  night.  He 
had  not  had  massage,  except  such  kneading  over  the  abdomen 
as  he  had  been  able  to  give  himself. 

"  In  this  case  no  opportunity  has  been  offered  of  testing  the 
stomach  contents  again,  but  it  is  highly  probable,  from  the 
decided  improvement  in  the  patient's  digestion,  as  well  as  in  his 


342  METHODS    OF    TREATMENT 

general  health,  that  the  gastric  glands  are  now  doing  much 
better  work. 

"  Reports  of  a  number  of  other  cases  might  be  added,  in 
which,  under  a  treatment  consisting  either  entirely  or  mainly 
of  the  administration  of  HCl  and  pepsin,  conditions  of  apepsia 
or  hypopepsia  improved  more  or  less  markedly,  the  gastric 
secretion  having  returned  to  the  normal.  AA'ithout  claiming 
that  such  fragments  of  clinical  experience  can  be  accepted  as 
denionstrating  beyond  question  that  HCl  stimulates  the  gastric 
glands,  it  must  be  admitted  that  a  strong  presumption  is  thus 
established  as  to  the  existence  of  such  an  action." 

Later  Experience  with  HCl. — During  the  twelve  years  which 
have  elapsed  since  the  foregoing  article  was  written,  not  only 
my  own  further  observations  in  a  large  number  of  cases,  but 
the  clinical  experience  of  a  majority  of  other  writers  upon  the 
subject  have  confirmed  the  views  and  results  therein  recorded. 

Pawlow,^  in  some  experiments  on  dogs,  failed  to  obtain 
evidence  that  HCl  has  a  directly  stimulating  effect  upon  the 
gastric  secretion,  but  this  failure  by  no  means  disproves  the 
significance  of  the  numerous  positive  findings  above  reported, 
and  the  results  of  recent  carefully  conducted  experiments  by 
myself.'  HCl  does  not  exert  an}"  sudden  stimulant  effect 
which  could  be  demonstrable  at  once,  but  rather  a  gradual  tonic 
influence  which  only  after  some  days  or  weeks,  and  sometimes 
not  until  after  months,  of  use  in  small  doses,  makes  itself  mani- 
fest in  the  form  of  an  increased  secretion. 

As  to  the  methods  of  administering  the  dihite  HCl,  the 
paper  above  reproduced  in  full  describes  that  which  has  proved 
most  effective  in  my  hands,  and  I  quote  also  the  following  from 
a  paper  by  myself,  read  by  invitation  before  the  Alabama  State 
Medical  Society,  April  15,  1902,  and  entitled  "The  Place  of 
Drugs  in  the  Treatment  of  Stomach  Troubles."^ 

■•  "  The  Work  of  the  Digestive  Glands,"  Philadelphia,  igo2. 
2  The  Place  of  Drugs  in  the  Treatment  of  Stomach  Troubles,  Inf.  Med. 
Mag.,  June,  1902. 
2  Loc.  cit. 


MEDICINAL    THERAPY    OF    DISEASES    OF    STOMACH  343 

"  111  the  condition  of  deficient  secretion  of  the  gastric  juice, 
especially  of  the  HCl — such  as  obtains  generally  in  old  cases  of 
chronic  gastric  catarrh  of  the  atonic  type,  and  even  also  in  some 
cases  of  chronic  nen-e  exhaustion  of  long  standing — an  entirely 
opposite  line  of  treatment  is  necessary.  In  many  of  these  cases 
nothing  effects  such  prompt  beneficial  results  as  the  administra- 
tion of  the  officinal  dilute  HCl  in  doses  of  from  5  to  30  drops, 
combined  usually  with  pepsin.  Rarely  have  I  found  it  advan- 
tageous to  increase  the  dose  beyond  the  latter  amount,  even 
when  the  deficiency  in  the  secretion  of  HCl  has  been  very  great, 
notwithstanding  the  recommendations  of  some  high  foreign 
authorities  in  favor  of  colossal  doses  of  the  acid.  These  rec- 
ommendations are  based  upon  theoretic  grounds,  especially  the 
fact  that  it  would  require  several  drams  of  the  dilute  HCl  to 
meet  the  requirements  of  the  stomach  in  the  digestion  of  a 
large  mixed  meal.  The  truth  is  that  the  usefulness  of  the  HCl 
as  a  remed}^  consists  mainly  in  its  stimulating  action  upon  the 
secreting  cells  of  the  stomach,  and  probably  not  to  any  consid- 
erable extent  upon  jts  power  of  supplying  the  place  of  the 
absent  or  deficient  gastric  juice.  This  point  I  have  fully  con- 
sidered in  several  previous  communications,  and  will  not 
enlarge  upon  here.  Let  it  suffice  that  my  own  experience, 
which  is  amply  supported  by  that  of  numerous  other  careful 
observers,  proves  beyond  cjuestion  that  HCl  does,  in  many 
cases,  gradually  bring  ud  the  secretion  of  the  normal  acid  of 
the  stomach  to  its  proper  level  when  deficient  or  even  almost 
absent  previously. 

"  Experience  demonstrates  also  that  very  large  doses,  and 
even  in  fact  moderate  doses,  sometimes  markedly  disagree  with 
stomachs  v/hich  careful  tests  show  to  be  greatly  in  need  of  the 
remedy.  A  burning  pain  is  often  produced  by  it  in  such  over- 
sensitive stomachs,  and  it  is  necessary,  therefore,  in  these  cases, 
to  administer  it  a  little  at  a  time.  The  appropriate  dose  should 
be  added  to  a  half  tumbler  of  water  and  taken  in  sips  every 
few  minutes  during  the  hour  following  each  meal.  I  am  accus- 
tomed to  prescribe  the  remedy  in  this  way  in  all  cases  where 


344  METHODS    OF    TREATMENT 

such  a  prescription  is  indicated,  and  my  patients  frequently 
allude  to  it  familiarly  as  '  the  sips.'  In  these  cases  character- 
ised by  deficient  secretion,  benefit  may  also  be  obtained  often 
from  the  administration  of  the  bitter  tonics,  especially  nux 
vomica,  quassia,  columbo,  etc.,  and  Ewald,  among  other  Ger- 
man writers,  strongly  recommends  condurango  bark  for  the 
same  condition."' 

Useful  as  is  HCl  as  a  remedy  when  deficient,  it  can  do  so 
much  harm  when  administered  in  unsuitable  cases  that  the 
practice  of  prescribing  it  without  any  tests  having  been  made, 
on  the  mere  suspicion  that  the  dyspepsia  complained  of  is  due 
to  a  lack  of  this  element  in  the  gastric  juice,  cannot  be  too 
strongly  condemned.  I  have  seen  numerous  cases  in  which 
serious  results  followed  its  administration  even  for  a  short 
time,  when  it  was  not  needed. 


LECTURE  XXXII 

DIGESTANTS,    ALKALIES,    AND    NATURAL 
SPRING  WATERS 

The  Digestants. — Theoretically,  pepsin  or  some  other  prep- 
aration capable  of  digesting  proteids  in  the  stomach  with  the. 
aid  of  HCl — such  as  papoid,  caroid,  pineapple  juice,  etc. — and 
also  for  other  classes  of  cases  the  rennet  ferment,  the  various 
extracts  of  pancreas,  etc.,  should  be  valuable  helps  in  many 
cases  of  indigestion,  but,  as  a  matter  of  fact,  it  is  probable  that 
few,  if  any,  remedies  are  frequently  prescribed  with  such  dis- 
appointing results.  The  chief  reason  for  this  is,  doubtless,  that 
they  are  not  given  to  the  right  cases,  or  else  not  at  the  right 
times  or  in  sufficient  -amounts.  My  own  observations,  con- 
firmed by  those  of  Einhorn  and  of  other  very  busy  internists, 
would  indicate  that  in  some  places,  if  not  in  civilized  countries 
generally,  a  majority  of  dyspeptics  have  too  much  HCl,  and 
probably  also  of  the  ferments,  in  their  gastric  juice,  and, 
therefore,  need  in  the  earlier  stages  of  their  malady,  alkalies, 
bismuth,  and  sedatives,  rather  than  digestants  of  any  kind. 

Again,  though  exceptionally,  the  gastric  juice  in  certain 
cases  does  not  contain  sufficient  pepsin,  while  HCl  is  yet  pres- 
ent in  normal  amount ;  more  frequently  when  one  is  deficient 
both  are,  and  in  such  cases  to  order  pepsin  or  any  proteolytic 
ferment  witliout  including  HCl  in  the  prescription,  is  to  ac- 
complish no  good  result  and  possibly  to  do  harm. 

A  series  of  experiments  carried  out  in  my  laboratory  in  1901 
showed  that  in  four  out  of  six  cases  the  addition  of  pepsin 
without  HCl  to  samples  of  chyme  in  test  tubes  taken  up  during 
the  height  of  digestion  produced  a  slight  retardation  of  the 
digestion  of  cubes  of  albumin  placed  in  the  tubes  at  the  same 

345 


34^  METHODS    OF    TREATMENT 

time.  These  four  samples  of  chyme  contained  free  HCl. 
though  in  somewhat  deficient  amount.  There  were  numerous 
?)ther  experiments  and  they  tended  to  prove  that  the  adminis- 
tration of  pepsin  alone,  even  when  HCl  seems  to  be  present  in 
normal  proportion,  is  ineffective,  neither  improving  the  digest- 
ive work  at  the  time  nor  producing  any  such  beneficial  after 
effect  as  results  from  the  administration  of  HCl. 

It  is  likel)^,  however,  that  there  are  occasional  exceptional 
cases  having  along  with  a  full  supply  of  HCl  a  deficiency  of 
pepsin,  and  that  in  such  cases  the  administration  of  some 
proteolytic  ferment  like  pepsin  might  prove  efficacious. 

The  same  series  of  experiments  showed  that  while  the  ad- 
ministration of  scale  pepsin  in  5-grain  doses  for  periods  of 
five  to  seventeen  days  did  not  effect  any  improvement  in  the 
work  of  the  peptic  glands,  dilute  HCl  in  lo-drop  doses  given 
three  times  a  day  for  five  to  six  days  markedly  increased  the 
subsequent  secretion  of  the  same  acid.  Moreover,  as  an  ad- 
ditional experiment,  six  specimens  of  chyme  extracted  from 
the  same  five  subjects  one  hour  after  a  test  breakfast  were  sub- 
jected to  the  following  tests  : 

"  Small  cubes  of  coagulated  egg  albumin  of  the  same  size 
were  prepared  and  one  of  these  introduced  into  each  of  four 
test  tubes  with  3  c.  c.  of  the  filtered  stomach  contents  taken  up 
one  hour  after  an  Ewald  breakfast.  Nothing  further  was  put 
into  tube  i ;  to  tube  2  two  grains  of  scale  pepsin  were  added ; 
to  tube  3  one  drop  of  dilute  HCl,  and  to  tube  4  both  pepsin  and 
HCl  were  added." 

The  tubes  were  kept  in  an  incubator  at  a  temperature  of 
approximately  38  C.  Of  the  tubes  to  which  HCl  alone  had 
been  added  four  out  of  the  six  showed  a  more  rapid  digestion 
than  in  the  control  tube.  In  the  same  proportion  of  the  tubes 
to  which  pepsin  alone  had  been  added  there  was  a  slower 
digestion  than  in  the  control — a  positive  retardation ;  but  in 
all  of  the  six  tubes  to  which  both  HCl  and  pepsin  had  been 
added  the  process  of  solution  was  more  rapid. 

Confirmatory  Clinical  Evidence. — A  limited  number  of  such 


DIGESTANTS^    ALKALIES,    NATURAL    SPRING    WATERS      347 

experiments,  no  matter  how  carefully  conducted,  cannot  be 
accepted  as  conclusive,  but  when  they  confirm  abundant  clinical 
experience  the  results  should  certainly  have  weight. 

Having  begun  earlier  in  my  practice  as  a  somewhat  routine 
plan  the  administration  of  HCl  and  pepsin  combined  in  smaller 
doses  of  the  fonner,  too,  than  are  commonly  advised  in  cases 
of  deficient  secretion  of  the  same,  and  having  found  that  my 
cases  almost  uniformly  improved  under  it,  the  percentage  of 
HCl  secreted  gradually  increasing,  I  have  continued  to  follow 
such  a  method.  Its  value  has  been  confirmed  by  my  own 
experiments  as  well  as  the  observations  of  other  clinicians,  not- 
withstanding the  disbelief  in  the  value  of  pepsin  expressed  by 
some  authors.  By  itself  the  latter  is  doubtless  generally  value- 
less, but  combined  with  HCl  it  is  highly  effective,  wherever  the 
tests  show  the  latter  to  be  deficient.  The  objectors  urge  that  in 
most  such  instances  pepsin  or  pepsinogen  is  present  in  the  gas- 
tric juice.  Doubtless ;  and  it  is  still  more  certainly  true  that 
the  rennet  ferment  is  almost  never  absent  from  the  gastric 
juice,  except  in  atrophy,  yet  the  Russian  experimenters  have 
demonstrated  that  in  atonic  dyspepsias  generally  no  digestant 
or  combination  of  them  acts  with  the  magical  efficacy  of  the 
natural  gastric  juice  taken  from  a  living  dog,  which  contains 
along  with  the  HCl  not  only  pepsin  and  rennin,  but  probably 
also  other  ferments  or  active  elements  which  chemists  have 
not  yet  been  able  to  discover  by  their  analyses. 

Useless  Pepsin  Compounds. — But  let  me  warn  you  to  place 
no  faith  in  the  pharmaceutic  monstrosities  which  are  said  to 
contain  pepsin  combined  with  pancreatin,  with  which  it  is 
positively  incompatible,  nor  those  in  which  it  is  combined  with 
wines  or  any  preparation  of  alcohol  which,  except  in  the 
weakest  dilutions,  interfere  with  its  action.  Nature  under- 
stands better  how  to  combine  it  so  as  to  have  its  work  done  ef- 
fectually. 

Pancreatic  Preparations, — Pancreatin  not  only  cannot  be 
combined  in  the  same  mixture  with  pepsin,  since  they  mutually 
destroy  each  other,  but  it  cannot  be  prescribed  with  any  benefit 


348  METHODS    OF    TREATMENT 

SO  long  as  pepsin  and  HCl  are  being  secreted  by  the  stomach, 
though  in  cases  of  deficient  secretion  of  the  latter  it  may  often 
be  used  helpfully  to  peptonize  artificially  milk,  porridges,  etc., 
before  these  are  ingested. 

It  may  also  render  effective  aid  when  administered  with  a 
small  amount  of  soda  to  patients  with  gastric  atrophy — when 
there  is  no  longer  any  gastric  juice.  But  while  the  various 
extracts  of  pancreas  act  best  in  an  alkaline  or  feebly  acid 
medium,  you  should  bear  in  mind  that  much  soda  in  these 
atrophic  cases,  according  to  recent  experiments,  is  likely  to 
diminish  the  secretion  of  the  pancreas  itself,  which  is  normally 
promoted  by  the  presence  of  some  free  HCl  in  the  duodenum. 
This  observed  fact  w^ould  lead  one  to  infer  that  since,  in  gastric 
atrophy,  dependence  for  digestion  must  be  placed  mainly  upon 
the  pancreatic  juice,  it  should  be  best  even  in  these  cases  to 
administer  HCl  (without  pepsin),  but  clinical  experience  has 
shown  this  to  be  commonly  ineffective  under  such  conditions. 

Alkalies  in  Gastro-intestinal  Disease. — The  alkalies  form  a 
most  important  class  of  remedies  in  certain  diseases  of  the 
stomach  and  intestines.  In  deficient  gastric  secretion  the 
mineral  acids  (HCl  being  the  best  of  them)  have  proved 
themselves  highly  advantageous  with  real  curative  virtues ; 
yet  they  can  be  dispensed  with.  One  can  get  on  without  them 
and  yet  hope  for  fairly  satisfactory  results.  If  the  patients  do 
not  progress  so  surely  toward  a  favorable  result,  they  at  least 
do  not  suffer  for  w^ant  of  them.  In  the  gastric  derangements, 
however,  accompanied  by  a  large  excess  of  HCl  with  severe 
acute  pain  or  other  urgent ,  symptoms  consequent  upon  the 
excessive  secretion,  we  have  no  efifective  medicinal  substitute 
for  full  doses  of  some  alkali  and  such  a  remedy  is  imperatively 
required.  Some  general  suggestions  as  to  the  dosage  and 
modes  of  administering  alkalies  in  such  cases  were  contained 
in  the  paper  above  cited  and  they  are  here  reproduced.^ 

"  The  administration  of  alkalies  is  generally  necessary  in 

^  The  Place  o£  Drugs  in  the  Treatment  of  Stomach  Troubles,  Int.  Med. 
Mag.,  June,  1902. 


DIGESTANTS,    ALKALIES,    NATURAL    SPRING    WATERS       349 

excessive  secretion  of  the  HCl  of  the  gastric  juice,  whether 
it  be  in  the  form  of  an  excess  of  the  same  during  the  digestive 
periods  only,  as  is  most  common,  and  known  as  hyperchlor- 
hydria,  or  a  persistent  flow  during  aU  the  twenty-four  hours 
of  every  day,  as  in  Reichmann's  disease,  or  a  paroxysmal  flov/ 
with  very  large  excess  for  a  few  days  at  a  time,  as  in  gas- 
troxynsis.  This  treatment  is  necessary  whether  the  HCl 
excess  is  a  merely  functional  derangement,  or  is  associated  with 
either  an  acid  gastric  catarrh  or  with  round  ulcer  of  the 
stomach.  The  selection  of  the  alkali  in  such  cases  is  not  a 
matter  of  indifference.  When  the  bowels  are  not  in  need  of  a 
laxative,  sodium  bicarbonate  in  doses  of  from  15  to  60  grains, 
given  two  hours  after  each  meal,  and  in  the  worst  cases  com- 
bined for  a  week  or  two  at  first,  with  small  or  moderate  doses 
of  either  belladonna  or  atropin,  will  be  usually  most  useful. 
Sometimes  it  is  better  to  administer,  at  the  same  periods,  a 
combination  of  sodium  bicarbonate  15  grains,  bismuth  subni- 
trate  or  subcarbonate  1.5  grains,  and  calcined  magnesia  10  to 
20  grains,  according  to  the  condition  of  the  intestines,  the  dose 
of  the  magnesia  being  adjusted  so  as  not  to  allow  constipation 
to  result  from  the  bismuth.  In  many  such  cases  magnesia, 
having  a  far  greater  alkalinity,  acts  better  than  soda,  since 
large  doses  of  soda  are  required  when  the  latter  is  given  alone. 

"  In  the  constipated  cases  a  similar  combination,  with  a 
sufficient  increase  of  the  magnesia  to  insure  regular  evacua- 
tions, usually  suits  well,  and  the  belladonna  here  affords 
valuable  assistance  in  bringing  about  a  freer  opening  of  the 
bowels.  The  HCl  excess  often  depends  upon  reflex  irritation 
from  a  movable  kidney,  and  then  drugs  will  do  little  good  till 
the  latter  can  be  held  in  its  normal  place.  When  the  hyper- 
chlorhydria  has  already  developed  into  gastric  ulcer,  the  op- 
portunity is  afforded  for  some  of  the  most  brilliant  results 
obtainable  in  the  therapeutics  of  any  chronic  disease."  But 
the  special  method  of  treating  gastric  ulcer  is  fully  discussed  in 
a  separate  lecture  under  that  head. 

,  The  alkaline  mineral  waters  deserve  special  mention  here. 


35°  METHODS    OF    TREATMENT 

They  include  particularly  the  Vichy,  Selters,  Carlsbad  and 
other  spring  waters  of  Europe  as  well  as  the  Saratoga  Vichy, 
Saratoga  Kissingen,  and  Bedford  Spring  waters  of  this 
country.  Perhaps  mention  ought  to  be  made  also  in  this 
connection  of  numerous  very  slightly  alkaline  waters,  such  as 
those  from  the  Poland  Spring  in  Maine,  and  those  from  several 
springs  in  the  vicinity  of  Waukesha,  Wisconsin,  besides  the 
many  much  advertised  lithia  waters,  the  latter  of  which  when 
natural,  however,  contain  as  a  rule  only  the  minutest  quantities 
of  lithia.  Few  of  these  contain  a  sufficient  proportion  of  any 
alkali  to  exert  a  noteworthy  antacid  action,  but  many  of  them 
seem  to  produce  a  beneficial  influence  upon  nutrition  quite  out 
of  proportion  to  their  mineral  contents.  A  large  part  of  this 
is  doubtless  due  to  the  diuretic  action  of  the  water  itself, 
which  the  patients  would  not  drink  so  freely  if  it  were  not 
supposed  to  possess  some  medicinal  properties ;  but  I  am  in- 
clined to  believe  that  the  minute  amounts  of  silica  and  other 
saline  ingredients,  even  in  the  very  small  proportions  present, 
increase  the  efficiency  of  the  water. 

Natural  spring  waters  as  a  rule  do  often  effect  results  which 
cannot  be  obtained  by  the  administration  of  equivalent  doses  of 
their  principal  mineral  constituents  in  artificial  solutions,  and 
when  patients  are  able  to  bear  the  increased  expense  of  such 
medication  you  may  sometimes  find  it  preferable  to  prescribe 
the  French  Vichy  waters  instead  of  sodium  bicarbonate,  or 
Bedford  water  when  you  desire  a  slight  laxative  action  in 
addition  to  an  antacid  one.  There  are  many  other  American 
alkaline  spring  waters  which  no  doubt  possess  valuable  reme- 
dial properties,  but  sufficient  experience  with  them  has  not 
yet  been  accumulated  to  warrant  dependence  upon  them.  The 
Saratoga  Vichy  water  is  said  to  answer  well  in  hyperchlor- 
hydria,  but  it  happens  that  my  experience  has  been  greater 
with  the  imported  Vichy,  and  in  urgent  cases  I  have  preferred 
full  doses  of  soda  or  magnesia  or  a  combination  of  these  with 
bismuth,  as  directed  in  my  lecture  on  that  affection. 

The  Effect  of  Alkalies  before  and  after  Meals. — Upon  one 


DIGESTANTS^    ALKALIES,    NATURAL  SPRING     WATERS       351 

point  concerning  which  there  seem  to  be  very  divergent 
opinions  held  by  authors,  I  desire  to  advise  you  strongly  and 
emphatically :  it  is  as  to  the  effect  of  alkalies  and  the  alkaline 
waters  upon  gastric  secretion.  Certain  writers  have  asserted 
that  an  alkali  given  before  eating  always  increases  the  secre- 
tion of  HCl,  and  given  after  meals  lessens  it.  This  is  not  true. 
This  piece  of  misinformation  has  been  handed  down  from  the 
time  of  Sidney  Ringer  at  least,  and  from  how  much  more  re- 
mote a  period  I  do  not  know.  The  facts  are  that  a  relatively 
small  dose  of  any  alkali,  or  alkaline  waters  in  which  the 
alkaline  element  predominates  over  the  saline  constituents,  will 
tend  to  stimulate  secretion  whether  taken  before  or  after  meals, 
(though  doubtless  rather  more  certainly  when  taken  upon  an 
empty  stomach),  and  that  in  a  relatively  large  dose  it  will  tend 
to  lessen  secfetion.  I  have  repeatedly  confirmed  this  in  practice, 
and  often  to  my  great  regret  as  well  as  to  the  sorrow  of  some 
of  my  worst  hyperchlorhydric  patients,  when,  in  trying  to 
restrain  the  very  excessive  execretion  of  HCl,  I  prescribed  too 
small  a  dose  of  some  alkali,  as,  e.  g.,  15  to  20  grains  of  sodium 
bicarbonate  to  be  taken  an  hour  or  two  after  eating,  since  the 
result  was  an  aggravation  of  the  trouble.  How  small  the  dose 
must  be  to  stimulate  and  how  large  to  depress,  depend  upon  the 
susceptibility  of  each  patient's  gastric  glands. 

The  Saline  or  Chloride  Waters. — There  is  a  marked  dif- 
ference in  the  effects  of  those  natural  spring  waters  which 
contain  predominantly  the  alkaline  carbonates  combined 
generally  with  some  of  the  sulphates  of  sodium,  etc.,  as  in  the 
Carlsbad  waters,  and  on  the  other  hand  such  waters  as  those 
of  Homburg  and  Kissingen  which  contain  chiefly  the  chlo- 
rides. The  former  in  the  usual  doses  lessen  hyperchlorhydria, 
and  depurate  generally,  being,  therefore,  particularly  well 
suited  to  plethoric  persons  who'  regularly  overeat  and  under- 
exercise.  The  chloride  waters,  on  the  contrary,  in  the  case  of 
patients  with  deficient  HCl  usually  stimulate  the  appetite  and 
gastric  secretion  and  tend  to  correct  catarrhal  tendencies  in  the 
gastro-intestinal  tract  without  weakening  or  depressing.     The 


352  METHODS    OF    TREATMENT 

persons — mostly  neurasthenics — who  are  benefited  by  these 
saHne  chloride  of  sodium  waters,  would  be  nearly  always 
iiTJured  by  a  course  at  Carlsbad,  and  in  some  instances  at  least 
the  converse  is  true.  Some  day,  it  is  to  be  hoped,  our  numer- 
ous American  spring  waters  will  have  been  sufficiently  studied, 
so  that  we  may  obtain  from  them  a  like  variety  of  effects  and 
prescribe  them  in  the  same  way  to  meet  definite  indica- 
tions. 

Since  the  foregoing  was  put  in  type,  I  have  had  the  pleasure 
of  going  over  the  ]MS.  of  Professor  von  Noorden's  monograph 
concerning  the  "  Effects  of  Saline  Waters  on  ^Metabolism  " 
(which  at  the  time  of  this  writing  is  going  through  the  press 
of  Messrs.  E.  B.  Treat  &  Co.,  of  Xew  York),  and  find  that  a 
series  of  very  carefully  conducted  experiments  and  clinical 
observations,  carried  out  by  himself  and  his  assistants,  some- 
what modifies  the  views  hitherto  generally  held  in  regard  to 
the  action  of  these  spring  waters. 

He  has  satisfactorily  established,  I  think,  that  as  used  in  the 
ordinary  dosage  in  connection  with  an  appropriate  diet,  both 
the  Homburg  and  Kissingen  waters  may  influence  favorably, 
not  only  most  cases  of  chronic  gastric  catarrh  associated  with 
hypochlorhydria,  but  also  a  certain  proportion  of  cases  of  acid 
gastric  catarrh,  and  perhaps  also,  some  cases  of  hyperchlorhy- 
dria  dependent  upon  reflex  or  other  causes.  The  good  effects 
in  the  latter  class  of  derangements  are  doubtless  due  in  large 
part  to  the  influence  of  such  waters  in  overcoming  constipa- 
tion, and  relieving  the  catarrhal  condition  in  both  stomach  and 
intestines,  thereby  improving  the  nutrition  generally. 

I  quote  here  the  exact  language  used  by  von  Noorden  in 
his  summing  up  regarcHng  the  effects  of  the  waters  in  ques- 
tion^ : 

"  In  numerous  cases  of  gastric  disorder,  particularh^  in  gas- 
tric catarrh,  the  use  of  saline  mineral  waters  leads  to  an  ac- 

1  "  Concerning  the  Effects  of  Saline  "Waters  (Kissingen,  Homburg)  on 
Metabolism;"  by  Prof.  Carl  von  Noorden  (Frankfort)  and  Dr.  Carl  Dapper 
Bad  Kissingen).     E.  B.  Treat  &  Co.,  New  York,  1904. 


DIGEST  ANTS,    ALKALIES,    NATURAL    SPRING    WATERS       353 

tive  and  permanent  increase  in  the  production  of  hydrochloric 
acid. 

''  In  numerous  cases  of  gastric  disorder  accompanied  by 
hyperacidity  (particularly  in  nervous  dyspepsia)  the  moderate 
use  of  saline  mineral  waters  leads  to  a  decrease  in  the  hydro- 
chloric acid  production,  and  a  decrease  of  the  subjective 
symptoms."' 


LECTURE  XXXIII 
TONICS,    STIMULANTS,    AND     SEDATIVES 

The  Nerve  Tonics. — In  true  cases  of  gastro-intestinal 
neurasthenia — nervous  dyspepsia — good  results  can  often  be 
obtained  from  the  giving  of  nerve  tonics  in  suitable  doses,  pro- 
vided no  one  drug,  and  still  less  a  combination  of  them,  be 
administered  long  enough  to  overstimulate.  The  most  useful 
drugs  for  this  purpose  I  have  found  to  include  the  hypophos- 
phites,  the  glycerophosphates,  iron,  arsenic,  gold,  silver,  qui- 
nine, the  valerianates,  and  small  doses  of  the  bromides  combined 
with  some  roborant  remedy.  The  bromide  of  sodium  in  doses 
of  5  to  lo  grains,  after  meals,  in  a  mixture  with  tincture  of  the 
chloride  of  iron  well  diluted  and  pleasantly  flavored,  will  often 
prove  effective,  when  not  permitted  to  constipate.  In  no  class 
of  cases,  however,  does  the  experience  and  personal  skill  of  the 
physician  count  for  so  much  as  in  the  manifold  complications 
of  neurasthenia  and  anaemia  with  more  or  less  well-defined 
disease  of  the  gastro-intestinal  tract  or  vague  derangements  of 
digestion  and  nutrition.  Inexperienced  physicians  usually 
make  the  mistake  of  prescribing  too  much  medicine — especially 
too  many  and  too  strong  nerve  tonics  in  these  as  in  other 
troublesome  cases.  Your  safest  rule  will  be  to  give  the  nerve 
tonics — which,  with  the  exception  of  iron,  act  chiefly  as  "  spurs 
to  a  tired  horse  "  in  most  cases — as  cautiously  and  sparingly 
as  possible,  beginning  with  small  doses  increased  as  necessary, 
and  not  to  continue  with  any  one  of  them — except  iron  for 
anaemic  patients — veiy  long,  rarely  over  two  to  four  weeks, 
and  only  so  long  if  it  has  agreed  perfectly  well. 

Belladonna  and  hyoscyamus  or  their  alkaloids  are  useful 
sometimes  in  hyperchlorhydria  and  in  bowel  obstruction,  but 

354 


TONICS,    STIMULANTS,    AND    SEDATIVES  355 

they  are  remedies  for  emergencies  and  their  prolonged  use  can 
do  much  mischief. 

Alcohol  Rarely  Necessary. — As  to  alcohohc  stimulants  on  the 
one  hand  and  the  more  powerful  sedatives  or  narcotics  on  the 
other,  with  increasing  experience  I  find  myself  prescribing  both 
classes  of  remedies  less  and  less.  When  patients  are  tired  or 
exhausted,  the  manifest  indication  is  for  rest  rather  than  for  a 
stimulant  of  any  kind,  unless  there  is  a  persistent  lack  of 
energy  in  some  organ  when  the  appropriate  tonic  drug  (pro- 
vided no  hygienic  or  mechanical  measure  will  effect  the  object) 
would  seem  generally  more  suitable  than  the  very  temporary 
stimulation  of  alcohol,  followed  speedily  by  its  inevitable  reac- 
tion with  then  increased  debility. 

HCl,  e.  g.,  is  the  best  stimulant  for  the  gastric  glands; 
electricity,  massage,  or  other  mechanical  excitant  for  the  gastric 
or  intestinal  musculature  (though  these,  in  suitable  dose,  are 
powerful  stimulants  of  secretion  also),  with  strychnine  or  some 
medicinal  purgative  as  a  less  desirable  substitute ;  the  Nauheim 
baths  and  exercises  are  the  best  cure  for  a  weakened  heart 
muscle  with  various  medicinal  heart  tonics  as  substitutes, 
which  are  superior  at  least  to  alcoholic  stimulants  because  their 
effects  are  longer  lasting,  even  though  at  the  best  not  very 
long.     See  Lecture  LXXXII. 

The  bromides  are  of  real  value  because  they  steady  an  un- 
stable nervous  system,  and  in  small  doses,  not  exceeding  5  to 
10  grains,  two  or  three  times  a  day  for  short  periods,  act  as 
tonics  rather  than  as  depressants,  though,  when  long  admin- 
istered, they  lower  the  strength  both  mental  and  physical  as 
well  as  most  of  the  bodily  functions. 

The  Relief  of  Pain  and  Insomnia  Produced  by  Disease  of 
the  Stomach  or  Bowels. — Opiates  and  other  narcotic  remedies 
are  exceptionally  recjuired  to  quiet  pain  which  cannot  be  other- 
wise controlled,  though  I  do  not  now  prescribe  them  once 
where  twenty  years  ago  I  would  probably  have  found  them 
necessary  fifty  times.  Alkalies  or  an  unloading  of  the  bowels 
will  relieve  most  pains  in  the  stomach  or  bowels,  with  the  help 


35^  METHODS    OF    TREATMENT 

sometimes  of  a  hot  wet  pack  or  an  active  counter-irritant 
locally. 

'  Hypnotics  are,  I  trust,  less  abused  than  they  were  when 
sulphonal  first  came  into  vogue  and,  like  all  such  remedies  upon 
their  original  introduction,  was  hailed  as  a  boon  to  in- 
somniacs— an  agent  which  was  said  to  soothe  mildly  and  harm- 
lessly, without  the  possibility  of  danger.  I  have  seen  at  least 
one  patient  made  insane  by  sulphonal  and  two  or  three  die  from 
the  prolonged  use  of  it  and  trional,  so  that  I  am  less  easily 
convinced  now  that  any  such  remedies  are  desirable  unless  for 
desperate  emergencies.  When  your  dyspeptic  patients  do  not 
sleep,  in  the  absence  of  brain  disease  or  of  any  clearly  recogniz- 
able painful  condition,  it  will  usually  be  because  of  a  seriously 
lowered  nerve  tone  which  calls  for  building-up,  not  lowering, 
agents,  such  as  all  the  hypnotics  and  narcotics  are  in  full  seda- 
tive doses ;  but  perhaps  the  most  frequent  exciting  cause  of 
wakefulness  will  be  found  to  be  indigestion  with  accumulations 
of  gas  in  the  stomach  or  bowels.  The  surest  remedy  in  these 
last  cases  will  be  that  which  will  stop  the  fermentation,  if  at 
the  same  time  measures  are  carried  out  designed  to  fortify  the 
strength  and  raise  the  nerve  tone  of  the  patient. 

Iron  and  its  Principal  Preparations. — It  is  probable  that  iron 
is  not  sufficiently  often  given  in  the  affections  of  the  stomach 
and  intestines.  The  fact  that  its  astringent  preparations 
frequently  increase  constipation  and,  at  least  in  full  doses  and 
when  not  properly  combined,  may  disturb  the  digestion,  has 
led  to  a  distrust  and  neglect  of  this  grand  remedy  in  a  class  of 
cases  for  which  at  times  it  is  able  to  do  very  much.  Chronic 
indigestion  in  most  of  its  forms  goes  hand  in  hand  with 
anaemia.  A  vicious  circle  is  soon  formed;  the  indigestion  pro- 
duces a  lowered  nutrition  with  impoverished  blood  and  these 
in  turn  increase  the  indigestion.  Iron  in  many  cases  can 
speedily  break  such  a  chain  of  sequences  and  supply  the  addi- 
tional energy  which  is  necessary  to  restore  the  digestive  power. 
Rven  the  fermentation  can  often  be  restrained  by  5  to  10  drops 
of  the  good  old-fashioned  tincture  of  the  chloride  of  iron  taken 


TONICS^    STIMULANTS,    AND    SEDATIVES  357 

after  meals  and  guarded,  as  previously  suggested  in  speaking 
of  nerve  tonics,  by  the  same  number  of  grains  of  sodium 
bromide  freely  diluted,  especially  if  there  be  added  to  the 
treatment  either  HCl  or  an  alkali,  accordingly  as  the  gastric 
secretion  is  deficient  or  excessive.  Such  a  combination  is  at 
once  tonic,  nervine,  and  antiseptic,  and  I  have  found  it  to  effect 
much  good  in  anjemic,  debilitated  dyspeptics  when  the  stomach 
was  not  irritable.  In  these  cases  constipation  nearly  always 
exists  anyway,  and  if  you  follow  the  methods  of  cure  I  shall 
lay  down  for  you  in  a  subsecjuent  lecture,  this  symptom  will 
usually  respond  to  your  treatment  satisfactorily  in  due  time,  in 
spite  of  the  iron — sometimes  all  the  sooner  because  of  the  im- 
proved digestive  power  and  increased  nerve  and  muscle  tone 
which  iron  gives. 

For  many  cases,  however,  blander  preparations,  such  as  the 
reduced  iron,  the  carbonate,  the  pyrophosphate  or  especially 
Blaud's  pills  are  better  borne  and  effect  the  desired  result  more 
certainly  because  of  the  combination  with  an  alkali  which  per- 
mits the  giving  of  very  large  doses  safely.  Another  most 
efficient  preparation  for  anaemic  nervous  patients  with  deficient 
gastric  secretion  is  the  modern  substitute  for  the  old  Parrish's 
Chemical  Food — Syr.  ferri  phosphatis — though  it  contains 
proportionately  a  good  deal  less  iron  than  the  others,  along 
with  much  dilute  phosphoric  acid. 

The  expensive  preparations  with  which  the  market  is  just 
now  flooded  are  no  better ;  most  of  them  are  not  so  good  as 
those  above  named.  The  so-called  organic  iron  compounds  are 
less  efficient  and  only  slightly,  if  at  all  better  borne  than  the 
blander  official  preparations,  so  that  there  is  rarely  an  excuse 
for  resorting  to  them.  However,  Pepto-Mangan  has  been  very 
largely  employed  with  good  results,  and  this  as  well  as  Ovofer- 
rin  and  other  similar  organic  compounds  of  iron  may  be  tried 
in  cases  in  which  the  stronger  iron  salts  disagree. 

The  Ferruginous  Mineral  Waters. — Ever  since  learning 
personally  from  Professor  Ewald,  in  1895,  that  it  was  a 
remarkably  effective  remedy,  I  have  prescribed  largely  the  Ron- 


35^  METHODS    OF    TREATMENT 

cegno  Water,  which  seems  to  be  Httle  known  in  this  country, 
and  have  almost  uniformly  been  pleased  with  the  results.  It 
(3omes  from  the  South  Tyrol,  and  is  so  strong  both  in  iron  and 
arsenic  that  a  tablespoonful  of  it  with  a  glass  of  any  pure  water 
makes  a  fairly  full  dose,  while  one  to  two  teaspoonfuls  after 
each  meal  (always  with  plenty  of  water)  prove  sufficient  for 
many  cases.  Small  doses  of  these  two  metals  usually  agree  best 
with  dyspeptics,  and  any  considerable  dose  of  this  strong  water 
might  disagree  in  decided  inflammatory  conditions  or  in  cases 
having  any  tendency  to  vomiting  or  diarrhea.  Ewald  often 
prescribes  also  the  Levico  iron  and  arsenic  water  from  another 
spring  in  the  South  Tyrol,  especially  for  the  gastric  neu- 
roses. 

There  are  many  other  famous  springs  of  iron  water,  includ- 
ing, especially  in  Europe,  those  of  Franzenbad  and  Elster. 
which  are  practically  recommended  by  Boas  because  in  their 
waters  the  iron  is  combined  with  large  amounts  of  alkaline 
and  saline  ingredients,  and  he  considers  iron  by  itself,  not  thus 
combined,  to  be  badly  borne  in  well-marked  dyspeptic  cases.  It 
is  certainly  true  that  iron  preparations  are  always  likely  to 
agree  best  in  even  cases  of  nervous  dyspepsia,  and  still  more  so 
in  serious  -gastric  or  intestinal  disorders,  when  combined  with 
one  or  more  alkalies  and  salines,  especially  mild  laxatives 
largely  diluted,  as  occurs  in  many  popular  iron  waters. 

The  list  of  the  mineral  springs  in  the  United  States  contain- 
ing iron  in  notable  quantities  is  a  very  long  one,  but  unfor- 
tunately most  of  them  are  yet  undeveloped,  their  virtues  known 
to  a  few  only,  and  their  valuable  medicinal  waters  scarcely  ob- 
tainable anywhere  away  from  the  localities  of  the  springs  them- 
selves. The  springs  at  Saratoga  and  Ballston  Spa,  New  York, 
are  alkaline,  saline,  and  laxative,  with  a  small  content  of  iron, 
while  the  Putnam  Spring  of  Saratoga  has  over  7  grains  of  iron 
to  the  gallon.  The  water  from  the  Londonderry  Litha  Springs 
of  New  Hampshire  contains  1.85  grains  of  iron  carbonate  and 
7.29  grains  of  lithia  carbonate  to  the  gallon  along  with  about 
the  same  proportion  of  carbonate  of  magnesium,  and  also  a 


TONICS^    STIMULANTS,,    AND    SEDATIVES  359 

very  much  larger  proportion  of  lime  salts,  which  are  less  desir- 
able for  many  cases. 

The  "Round"  Spring  at  Aurora  Springs,  Missouri,  contains 
about  7  grains  of  iron  tO'  the  gallon,  and  among  other  iron 
springs  of  some  note  are  the  Bath  Alum  and  Rock  Enon 
Springs, Vii'ginia;  the  Topeka  Mineral  Wells, Kansas;  Brown's 
Wells,  ^Mississippi;  and  the  Adirondack  ^Mineral  Spring  and 
Oak  Orchard  Acid  Spring,  New  York.  At  Hammonton, 
Xew  Jersey,  half-way  between  Philadelphia  and  Atlantic  City, 
there  is  a  spring  the  water  of  which  contains  13.63  grains 
of  iron  to  the  gallon,  a  much  larger  proportion  than  any  of 
those  above  named  (so  far  as  their  analyses  are  known)  except 
the  very  strong  arsenic  iron  waters  of  the  South  Tyrol. 

The  Bismuth  Preparations,  and  Cerium  Oxalate. — The  salts 
of  bismuth  are  of  prime  importance  in  the  treatment  of  many 
digestive  disorders,  and  in  the  same  class  may  well  be  placed 
the  oxalate  of  cerium,  which  is  equally  insoluble  and  has  a  very 
similar  sedative  action  upon  the  mucous  membranes.  The 
latter  drug,  however, "  while  it  seems  to  exert  less  antiseptic 
and  astringent  action  than  the  bismuth  salts,  goes  beyond  these 
in  influencing  apparently  the  pneumogastric  center  either 
directly  or  reflexly,  insomuch  that  it  often  helps  to  control 
reflex  nausea  as  well  as  coughs. 

The  bismuth  preparations  are  nearly  identical  in  their  action, 
except  that,  as  previously  explained,  the  subcarbonate  is  some- 
what more  alkaline,  and  the  salicylate  rather  more  antiseptic. 
I  have  never  been  able  to  observe  any  superior  virtues  of  any 
kind  in  the  subgallate,  and  indeed,  whether  prescribing  for 
astringent,  antiseptic,  or  local  sedative  effects,  have  usually 
found  the  subnitrate  about  as  good  as  any  other  of  the  salts. 

The  possibilities  of  bismuth  for  good  are  often  not  fully 
realized,  because  it  is  given  upon  a  full  stomach  instead  of  an 
empty  one  and  in  far  too  small  doses.  As  a  sedative  and 
astringent  in  gastric  ulcer,  for  instance,  doses  of  20  to  60 
grains  are  rec|uired.  In  such  doses  on  an  empty  stomach  it 
proves  exceedingly  effective. 


360  METHODS    OF    TREATMENT 

The  Bland  Oils. — Olive  oil  and  cottonseed  oil  (and  probably 
also  linseed  oil,  thoug'h  I  have  had  less  experience  with  this 
internally)  seem  to  exert  nO'  real  dynamic  action,  but  for  that 
very  reason  are  most  valuable  as  mechanical  remedies — cures 
— in  constipation.  Probably  the  most  highly  refined  petroleum 
oils  may  be  equally  free  from  medicinal  influence,  but  cosmo- 
line,  vaselin,  and  albolene,  all  of  which  I  have  made  full  trials 
of,  dO'  in  time  depress  weak  hearts  a  little.  They  act  even 
better  than  the  bland  vegetable  oils  in  overcoming  constipation, 
when  taken  by  the  mouth,  since  they  make  no  call  whatever 
upon  the  digestive  juices,  nO'  attempt  seeming  to  be  made  by 
the  latter  to  act  upon  them,  and  no  disorder  of  the  digestion 
results — rather,  on  the  contrary,  an  improvement  of  it  in  conse- 
quence, doubtless,  of  their  help  in  keeping  the  lower  bowels 
unloaded.  Dr.  A.  L.  Benedict  has  discovered  a  firm  which  is 
said  to  purify  the  coal  oil  so  thoroughly  that  no  toxic  product 
remains  in  the  oil.  The  latter  is  called  Purpetrol.  My  ex- 
perience with  this  preparation  has  not  been  large,  but  it  has 
proved  efficient  in  a  number  of  cases.  It  exerts  very  little,  if 
any,  depressing  effect  on  the  heart. 

In  my  experience  during  the- past  year,  the  cotton-seed  oil 
injected  *nto  the  bowel  at  bedtime  in  doses  of  2  to  6  ounces, 
and  allowed  to  remain  till  morning,  has  succeeded  in  a  large 
minority,  if  not  a  majority,  of  all  patients  suffering  from 
chronic  constipation,  in  curing  the  disease  when  the  patients 
would  persevere  with  it  and  follow  out  at  the  same  time  a 
proper  regimen,  including  gymnastic  exercises,  a  suitable  laxa- 
tive diet,  and  in  the  worst  cases  a  course  of  massage  and 
electricity. 

The  effect  of  all  these  bland  oils  seems  to  be  to  soften  the 
feces  and  lubricate  the  mucous  membrane ;  and,  besides,  they 
act  locally  as  sedatives,  soothing  an  irritated  mucous  mem- 
brane. 


LECTURE  XXXIV 

ANTISEPTICS,  ASTRINGENTS,  AND  LAXA- 
TIVES—MINUTE DOSES  OF  CERTAIN 
DRUGS 

Antiseptic  remedies  are  usually  disappointing.  They 
sometimes  seem  efficient  in  the  milder  cases  of  fermentation 
or  putrefaction — cases  in  which  a  more  careful  diet  with  more 
exercise  and  attention  to  the  bowels  are  nearly  always  suffi- 
cient of  themselves  to  cure ;  but  when  there  is  serious  and  per- 
sistent gas  formation,  as  in  catarrhal  affections  and  in  cases 
with  decidedly  weakened  motor  power  of  the  stomach  or 
intestines,  antiseptics  as  well  as  other  remedies  fail  until  the 
cause  can  be  removed.-  Stomach  washing,  laxatives,  or  colon 
douches — measures  which  rapidly  remove  the  fermenting 
remains  of  food  or  feces  from  the  weak-walled  viscera — are, 
in  such  cases,  often  the  only  really  effective  palliatives  even, 
while  appropriate  mechanical  modes  of  treatment  are  nearly 
always  required  to  cure. 

Carbolic  acid,  which  is  often  given  and  helps  somewhat  to 
restrain  moderate  fermentation  in  the  stomach,  is  only  safe 
or  pemiissible  when  the  gastric  secretion  is  low,  since  it  rap- 
idly stimulates  it,  often  aggravating  or  causing  hyperchlorhy- 
dria  even  when  ingested  per  rectum.  The  sulphocarbolates  are 
inefficient  except  in  the  largest  doses,  and  then  probably  act  as 
carbolic  acid  upon  the  glands.  The  salicylates  restrain  fer- 
mentation to  some  extent;  but,  like  the  former  remedies,  only 
more  so,  weaken  the  heart  if  long  administered.  Bismuth  in 
full  doses  is  mildly  antiseptic,  but  constipates. 

Probably  the  safest  antiseptics,  when  otherwise  indicated, 
are  nitrate  of  silver  and  tincture  of  the  chloride  of  iron,  since 

361 


362  METHODS    OF    TREATMENT 

both  are  tonics;  the  former  exerts  a  good  effect  in  doses  of 
one-twelfth  to  one-quarter  grain  in  catarrhal  cases  (combined 
Vith  bismuth  subnitrate),  especially  in  chronic  acid  gastritis; 
and  the  latter,  in  5-  to  lo-drop  doses,  well  diluted,  combined 
frequently  with  5-grain  doses  of  sodium  bromide  three  times 
a  da}^,  agrees  better  in  atonic  cases  accompanied  by  excessive 
fermentation.  The  iron  I  have  seen  markedly  and  quickly  im- 
prove the  motor  function  of  some  stomachs. 

Resorcin,  thymol,  menthol,  spirits  of  chloroform,  and 
numerous  other  drugs  credited  with  antiseptic  powers,  may 
prove  useful  auxiliaries  to  more  curative  treatment  for  short 
periods,  but  none  of  them  can  be  safely  continued  long,  and  all 
of  them  will  be  likely  to  fail  you  at  times  in  cases  in  which  they 
seem  most  needed.  Sodium  benzoate,  and  ammonium  benzo- 
ate  act  efficiently  in  some  mild  cases,  and  salol  has  decided 
antiseptic  power;  but  these  have  the  same  limitations  and  ob- 
jections as  the  drugs  previously  mentioned. 

Astringents  are  not  abused  as  much  as  laxatives,  merely 
because  diarrhea  is  not  as  frequent  as  constipation,  but  a 
wrong  use  of  them  is  responsible  for  much  suffering  and 
numerous  deaths,  especially  in  children.  I  recall  with  sorrow 
the  ill  success  that  I  had  in  treating  such  cases  in  my  earlier 
years  of  practice  while  a  zealous  believer  in  the  efficacy  of 
combinations  of  astringents  with  opium.  These  combinations 
are  often  temporarily  effective,  but  the  flux  generally  returns 
in  aggravated  form  after  being  checked  for  a  time  with  any 
of  the  stronger  astringents,  even  in  spite  of  a  persistence  with 
them  in  the  largest  allowable  doses;  this  is  almost  invariably 
so  in  chronic  forms  of  diarrhea,  and  especially  so  in  dys- 
entery. 

Bismuth,  which  possesses  only  feeble  astringent  powers,  is 
niost  useful  in  catarrhal  affections  of  the  alimentary  canal, 
and  this  chiefly  because  of  its  locally  emollient  virtues  as  well 
as  probably  its  slight  antiseptic  influence.  Its  various  salts 
have  all  toxic  properties  and  can  do  harm  in  the  colossal  doses 
given  for  x-ray  work.      (P.  88.)      The  subcarbonate,  being 


ANTISEPTICS,    ASTRINGENTS,    AND  LAXATIVES  363 

the  most  alkaline,  probably  has  some  advantages  in  hyper- 
chlorhydria,  and  the  salicylate  is  somewhat  more  antiseptic 
than  its  other  salts. 

Laxatives  and  purgatives  constitute  a  very  important  class 
of  remedies,  though  perhaps  none  are  more  frequently  abused. 
The  need  of  regular  and  complete  alvine  evacuations  is  impera- 
tive ;  no  case  of  indigestion  can  be  even  improved  when  this 
function  is  imperfectly  performed,  but,  on  the  other  hand,  one 
might  add  with  truth  that  the  digestion  is  never  really  sound 
so  long  as  laxatives  have  to  be  regularly  administered  to  secure 
bowel  movements. 

Laxatives  and  purgatives,  then,  are  very  necessary  for  emer- 
gencies, sometimes  helpful  in  overcoming  obstruction,  and 
useful  almost  as  a  routine  measure  in  the  beginning  of  the 
treatment  for  diarrhea,  but  harmful  usually  when  depended 
upon  as  a  prolonged  means  of  treatment  in  chronic  constipa- 
tion ;  yet,  in  the  more  intractable  forms  of  the  trouble,  when  a 
cure  is  out  of  the  question,  a  judicious  alternation  of  some  of 
the  milder  laxatives  may  be  necesary  as  a  choice  of  evils — 
safer,  usually,  than  a  constant  dependence  upon  enemas  of 
water  or  any  aqueous  solutions. 

If,  however,  we  may  be  allowed  to  include  among  laxatives 
such  bland  vegetable  oils  as  olive,  cottonseed,  and  linseed  oil, 
the  two  former  of  which  in  particular  scarcely  possess  any 
real  medicinal  properties,  it  cannot  be  said  that  all  remedies  of 
this  class  are  useless  as  a  means  of  curing  constipation,  though 
most  of  them  certainly  are.  When  given  by  enema  in  doses 
of  two  to  six  ounces  at  bedtime,  together  with  a  suitable  diet 
and  sufficient  exercise,  they  do  not  often  fail  to  cure,  acting 
mechanically  as  solvents  of  the  feces  and  lubricants  of  the 
intestinal  mucous  membrane. 

In  catarrhal  dysentery  the  saline  laxatives  constitute  the  best 
form  of  treatment — full  aperient  doses  at  first  and  smaller 
doses  at  three-  or  four-hour  intervals  later.  Castor  oil  and 
calomel  in  moderate  purgative  doses  are  still  the  best  remedies 
to  clear  out  the  alimentary  canal  in  beginning  the  treatment  of 


364  METHODS    OF   TREATMENT 

diarrhea;  very  small  doses  of  the  same,  from  one-hundredth 
to  one-tenth  of  the  purgative  dose,  are  often  the  most  efficient 
means  of  treating  the  same  disease  later,  after  a  complete  emp- 
tying of  the  bowels.  Similar  minute  doses  of  podophyllin  are 
also  very  effective,  especially  in  painless  watery  forms  of 
diarrhea  either  in  afebrile  conditions  or  in  typhoid  fever.  The 
following  case,  previously  reported  by  me,^  shows  in  a  striking 
way  what  very  small  doses  of  podophyllin  and  again  similar 
doses  of  Fowler's  solution  of  arsenic  can  occasionally  do  in 
desperate  forms  of  diarrhea,  after  opium  and  astringents  have 
failed : 

"  Early  in  August,  1886,  before  the  underground  sewerage 
had  been  generally  introduced  into  the  hotels  of  Atlantic 
City,  a  girl  of  thirteen  developed  a  violent  attack  of 
typhoid  fever.  Before  the  end  of  the  first  week  the  child 
lay  in  a  stupor,  with  bowels  moving  involuntarily  a  dozen  or 
more  times  a  day.  Dr.  Julius  Kaemmerer,  lately  of  Philadel- 
phia, a  physician  of  great  experience  and  ability,  was  associ- 
ated with  me  in  the  case.  The  outlook  for  the  child  having 
become  very  bad,  a  distinguished  consultant  was  called  from 
Philadelphia.  The  usual  astringents,  bismuth,  opium,  and 
even  lead,  were  given  persistently  without  effect.  Another 
consultant  from  the  same  city,  a  gentleman  of  the  highest 
eminence  and  of  world-wide  reputation,  was  now  sent  for  to 
see  the  girl.  Other  astringents  were  tried  in  the  hope  of 
checking  the  exceedingly  profuse  diarrhea,  which  was  fast 
exhausting  her,  but  all  to  no  avail.  Our  consultants  made  but 
one  visit  each,  returning  afterward  to  Philadelphia,  and  so  had 
little  opportunity  to  display  their  undoubted  skill  and  fertility 
of  resource.  The  case  was  now  desperate  in  the  extreme,  and 
we  had  scarcely  a  hope  that  death  could  be  averted.  At  this 
juncture  the  writer  recalled  some  fortunate  experiences  with 
comparatively  small  doses  of  podophyllin  in  severe  diarrhea. 
It  was  remembered  that  podophyllin  specially  affects  the  small 
intestine,  the  part  in  which  the  most  characteristic  pathologic 
changes  are  found  in  enteric  fever,  and  since  Dr.  Anstie's 
experiments,   quoted   by  Professor   Ringer,   showed  that  the 

■•  The  Primary  and  Secondary  Action  of  Drugs,  Lotidon  Practitioner, 
April  and  May,  1888. 


ANTISEPTICS^    ASTRINGENTS,    AND    LAXATIVES  365 

drug  in  large  doses  caused  intense  congestion  and  even  ulcera- 
tion of  the  small  intestines,  it  was  believed  that  a  suitable  dose 
should  exert  an  opposite  or  restorative  action  upon  the  same 
part.  Dr.  Kaemmerer,  though  not  acquainted  with  such  a 
use  of  the  drug,  willingly  consented  to  the  trial,  since  we  had 
pretty  well  exhausted  all  the  usual  measures,  and,  indeed,  the 
patient's  stomach  had  become  irritable,  so  that  she  could 
retain  but  little  of  anything.  Then,  stopping  all  other  medi- 
cines, we  administered  i-i20th  of  a  grain  of  podophyllin  with 
a  little  sugar  every  third  hour.  After  the  third  dose  a  marked 
improvement  set  in.  The  discharge  from  the  bowels  was  rap- 
idly checked,  until  within  twenty-four  hours  the  stools  almost 
entirely  ceased,  and  my  colleague  even  expressed  the  appre- 
hension that  the  medicine  might  prove  too  astringent. 

"  The  effect  upon  the  temperature,  which  had  been  ranging 
between  103°  and  104°  to  104.5°  F.,  was  quite  extraordi- 
nary. Quinine  had  been  used  at  an  earlier  stage  with  little 
effect,  and  fairly  full  doses  of  antipyrin  produced  absolutely 
no  favorable  impression,  though  we  had  neither  of  us  seen  it 
fail  before.  But  coincidently  with  the  correction  of  the  diar- 
rhea after  beginning  podophyllin,  there  was  a  marked  decline 
in  the  temperature,  amounting  at  first  tO'  about  two  degrees 
in  twenty-four  hours.  The  subsequent  treatment  was  mainly 
of  a  supporting  character  with  occasional  remedies  for  a  pul- 
monary complication,  which  at  times  gave  trouble,  and  the  im- 
provement, with  the  exception  of  such  complication,  thence- 
forth went  on  steadily  till  the  temperature  reached  the 
normal. 

"  After  the  temperature  had  remained  normal  for  a  week, 
there  occurred  on  the  15th  of  September  a  relapse,  the  tempera- 
ture rising  on  the  i6th  to  105.4°,  higher  than  at  any  time 
before.  There  were  again  frequent  involuntary  stools,  with 
yet  more  profound  adynamia,  as  well  as  delirium  and  stupor. 
Podophyllin  was  again  tried  in  the  same  doses,  and  now  failed. 
We  then  resorted  to  Fowler's  solution  in  doses  of  one-eighth 
of  a  drop  every  two  hours.  Since  arsenic,  in  full  doses,  pro- 
duces a  violent  choleraic  condition,  probably  by  paralysis  of  the 
vaso-motor  nerve  supplying  the  stomach  and  intestinal  tract, 
it  was  reasoned  that  small  doses  should  exert  an  opposite,  i.  e., 
a  tonic  or  restorative  action  upon  the  same  tract.  The  effect 
was  as  prompt  and  satisfactory  as  had  been  that  of  the  podo- 
phyllin in  the  former  attack.  The  bowels  were  speedily 
checked,   the   temperature   rapidly   fell,    touching  the   normal 


366  METHODS    OF    TREATMENT 

again  by  September  23.     Thenceforward  convalescence  was 
uninterrupted,  very  little  other  medicine  being  given." 


I  could  instance  numerous  other  cases  in  my  experience  in 
which  one-hundredth  of  grain  doses  of  podophyllin  proved 
promptly  efficient  in  controlling  similar  severe  forms  of  diar- 
rhea, both  acute  and  chronic. 

The  Usefulness  of  Certain  Drugs  in  Minute  Doses — Cup- 
rum Arsenite. — It  was  John  Wesley,  I  think,  who  objected  to 
letting  the  devil  have  all  the  good  tunes,  and  whatever  wicked- 
ness may  still  be  imputed  to  the  homeopaths,  I  never  could  see 
the  wisdom  of  letting  them  monopolize  any  really  efficient 
remedies.  In  this  connection  it  is  worthy  of  note  that  it  was 
in  my  practice  in  Atlantic  City  some  twenty  or  more  years  ago 
that  minute  doses  of  arsenite  of  copper  were  first  given  a  sys- 
tematic trial  by  any  physician  of  the  regular  school.  I  related 
my  experience  with  it  in  colic  and  diarrhea  to  Dr.  John  Aulde 
of  Philadelphia,  and  in  consequence  of  his  enthusiastic  pub- 
lished reports  concerning  its  efficacy,  it  rapidly  attained  such 
popularity  that  for  many  years  past  most  of  the  manufacturing 
pharmacists  have  included  it  in  their  lists  of  tablet  triturates.  It 
has  since  been  so  greatly  abused  by  administering  it  in  cases  for 
which  it  was  unsuitable,  and  in  too  large  doses,  that  its  popu- 
larity has  of  late  been  waning;  but  it  remains  true  that  in  doses 
of  one-thousandth  to  one-five  hundredth  of  a  grain  repeated 
every  fifteen  to  thirty  minutes,  arsenite  of  copper  will  often 
control  severe  intestinal  colics  dependent  upon  spasmodic  con- 
tractions of  the  circular  muscular  fibers  of  the  intestines, 
whether  the  accompanying  condition  be  one  of  spastic  constipa- 
tion or  colicky  diarrhea.  But  it  will  not  cure  appendicitis  or 
peritonitis,  nor  will  it  remove  any  obstruction  of  the  intes- 
tines not  dependent  upon  spasm,  and  it  is  useless  and  danger- 
ous usually  to  push  its  administration  beyond  a  few  hours,  at 
the  most,  since  it  ordinarily  proves  effective  in  that  time  if  it 
ever  will,  and  even  such  small  doses  can  produce  toxic  effects 
if  continued  long. 


ANTISEPTICS,    ASTRINGENTS,    AND    LAXATIVES  3^7 

If  any  of  you  should  be  interested  in  the  modus  operandi  of 
medicines  in  such  minute  doses,  you  will  find  the  subject  fully 
discussed  in  my  London  Practitioner  paper  above  cited.  I 
therein  explained  it  in  strict  accordance  with  the  scientific  law 
that  overstimulation  always  produces  secondary  depression, 
and  that  in  the  case  of  certain  drugs,  including  most  of  the 
purgatives  especially,  we  have  been  accustomed  to  avail  our- 
selves only  or  chiefly  of  the  large-dose,  secondary,  and  often 
toxic,  action,  while  the  homeopaths  limit  themselves  exclusively 
(whenever  they  adhere  closely  to  their  principles)  to  the  oppo- 
site primary  small-dose  action,  which  is  always  stimulant  to  the 
nerve  centers  or  other  parts  affected,  though  if  this  chance  to 
be  an  inhibitory  nervT,  the  result  of  its  stimulation  must  be  a' 
lessening  of  function  in  the  structure  supplied  by  it.  Thus 
the  action  is  really  antipathic,  not  homeopathic  at  all,  since 
nearly  all  disease  signifies  weakness  and  depression  in  the 
diseased  structure  itself,  in  its  regulating  center,  or  in  the 
ner^'es  or  vessels  supplying  it. 

But  we  of  the  regular  school  also  habitually  administer  many 
remedies  for  their  primaiy  small-dose  effect  only,  avoiding 
strictly  the  large  doses  which  would  produce  their  physio- 
logic or  toxic  action.  Among  such  remedies  may  be  men- 
tioned arsenic,  most  of  the  metallic  salts,  hydrocyanic  acid, 
alcohol,  and  ether  and  chloroform  internally.  Other  drugs 
we  administer  in  both  small  and  large  doses  for  totally  dif- 
ferent and  often  opposite  effects.  These  include  tartar  emetic 
and  ipecac,  which  in  quite  small  doses  act  as  expectorants,  and 
the  latter  at  least,  as  an  anti-emetic,  with  no  depression,  while 
in  large  doses  they  produce  vomiting  and  depression — when 
pushed,  marked  prostration.  Calomel  is  largely  used  by  pedi- 
atrists  in  small  doses  to  control  diarrhea  in  children,  and  the 
bichloride  has  been  lauded  as  a  tonic  blood-maker  in  certain 
cases,  while  the  purgative,  depressing,  and  tissue-destroying 
influence  of  mercury,  in  its  larger  range  of  dosage,  is  well 
known.  Certain  other  drugs,  such  as  the  drastic  cathartics, 
the  vermifuges,  and  the  astringents,  we  regularly  administer 


368 


METHODS    OF    TREATMENT 


for  one  of  their  secondary  or  physiologic  effects  only.  It 
would  seem  that  our  therapeutics  might  gain  much  if  the 
materia  medica  were  to  be  studied  anew,  and  a  clear  state- 
ment made  regarding  each  drug  as  to  its  powers  in  each  of  its 
ranges  of  dose.  The  bugaboO',  homeopathy,  ought  no  longer 
to  stand  in  the  way  of  progress  in  this  direction. 


PART  IV 

THE     GASTRO-TNTESTINAL 
CLINIC 


LECTURE  XXXV 

INTRODUCTORY— THE       CLASSIFICATION 
OF  DISEASES 

In  Part  I,  have  been  rehearsed  briefly  certain  elementary 
and  basic  facts,  anatomic,  physiologic,  etc.,  which  should  assist 
you  somewhat  in.  the  study  of  our  subject.  In  Part  II,  have 
been  discussed  the  various  methods  of  examining  patients  in 
whom  there  is  reason  to  suspect  the  existence  of  disease  of 
the  stomach  or  intestines.  And  in  Part  III  you  have  had  pre- 
sented to  you  rather  full  descriptions  of  the  methods  in  general 
by  means  of  which  such  disease  can  be  best  remedied.  Now  we 
come  to  the  still  more  important  part  of  our  task,  the  consid- 
eration individually  of  the  diseases  in  question. 

At  the  threshold  of  this  study  arises  the  question  of  classifi- 
cation— nosology.  Various  plans  have  been  followed  by 
others.  Most  authors  have  admitted  the  desirability  of  basing 
their  classifications  so  far  as  possible  uj)on  anatomic  and  patho- 
logic grounds,  but  all  have  been  obliged  to  admit  also  that  many 
clinical  pictures  must  be  recognized  and  treated  as  distinct  enti- 
ties for  which  no  well-defined  pathologic  basis  yet  exists.  They 
differ,  however,  widely  in  their  methods  of  drawing  the  lines. 
Several  eminent  authors,  for  example,  refuse  to  consider  as  a 
distinct  disease  such  a  conspicuous  anatomic  and  pathologic  con- 
dition as  gastric  dilatation,  and  insist  upon  considering  it  under 
a  term  having  reference  to'the  atony  or  insufficiency  of  the  gas- 
tric muscles  upon  which  it  usually  depends.  Then,  nervous  dys- 
pepsia and  the  gastric  neuroses  generally  are  terms  restricted 
by  some  to  a  comparatively  few  obscure  affections  not  other- 
wise explicable,  while  others  expand  them  widely,  including 
under  them  all  the  derangements  of  secretion  as  well  as  the 

371 


372  THE    GASTRO-INTESTINAL    CLINIC 

motor  and  sensory  disturbances.  I  shall  try  to  take  a  middle 
and  conservative  ground  in  this  respect.  Without  disputing 
that  both  excessive  and  deficient  secretion  of  HCl  are  often 
attributable  merely  to  nervous  causes,  I  shall  describe  these 
very  frequent  and  important  affections  to  you  under  titles  that 
do  not  imply  any  special  theory  as  to  causation.  They  consti- 
tute symptom  groups  calling  for  special  forms  of  treatment 
additional  to,  and  very  different  from,  that  required  for  the 
original  nervous  or  other  affections  to  v^hich  they  are  second- 
ary; and,  moreover,  they  may  result  also  from  inflammations 
of  the  gastric  mucous  membrane  as  well  as  from  other  causes, 
including,  acording  to  my  own  observations,  besides  those  of 
other  writers,  movable  kidney — perhaps  also  the  displacements 
of  other  abdominal  organs — gall-stones,  renal  calculi,  etc. 
There  are  abundant  reasons,  then,  for  considering  these  affec- 
tions under  separate  names. 

I  am  inclined  to  agree  rather  with  Leube  than  with  some  of 
the  more  recent  writers  in  limiting  the  term  Nervous  Dyspep- 
sia to  those  gastric  or  intestinal  derangements  of  apparent 
nervous  origin  for  which  no  anatomic  or  pathologic  basis  has 
yet  been  discovered.  For  example,  whether  or  not  hyperchlor- 
hydria  can  cause  gastric  ulcer  and  proliferative  gastritis,  these 
latter  affections  are  now  believed  to  be  capable  of  producing 
hyperchlorhydria,  so  that  not  all  cases  of  the  latter  at  least  can 
be  properly  classed  as  neuroses.  In  like  manner,  certain 
obscure  gastric  pains  which  are  now  usually  called  neurotic,  or 
at  least  neuralgic — gastralgic — are  likely  to  result  really  from 
perigastric  adhesions  or  other  undetermined,  but  none  the  less 
actual,  anatomic  lesions.  The  truth  is  that  the  nervous  system 
is  intimately  involved  with  every  derangement  of  the  health 
in  whatsoever  part  or  organ  it  shows  itself,  regardless  of 
whether  such  part  or  organ  is  itself  structurally  diseased  or 
not;  but  the  opinion  is  growing  that  the  difference  between 
what  are  called  functional  diseases  and  those  known  to  be 
organic    is  less  than  was  formerly  supposed. 

It  is  difficult  to  conceive  of  the  possibility  of  any  consider- 


THE    CLASSIFICATION    OF    DISEASES  373 

able  or  prolonged  disturbance  of  function  that  does  not  involve 
at  least  a  slight  change  of  structure,  however  transient  in  dura- 
tion. And  the  longer  such  a  so-called  functional  disease  lasts, 
the  greater  is  likely  to  be  the  structural  change  accompanying 
it.  For  example,  whenever  on  account  of  the  reflex  irritation 
from  a  movable  kidney,  an  overtaxed  brain,  or  merely  over- 
eating, the  gastric  glands  are  stimulated  into  excessive  secre- 
tion and  we  have  the  familiar  picture  of  hyperchlorhydria  set 
up,  it  is  inconceivable  that  the  glands  remain  the  same  as  under 
normal  conditions.  They  are  necessarily  swollen,  congested, 
and  the  blood  supply  to  them  is  unduly  increased.  This  hyper- 
remia  might  properly  enough  be  spoken  of  as  functional  when  it 
is  transient  and  the  glands  return  within  a  few  hours  or  even 
days  to  the  normal  again;  but  when  it  persists  for  weeks  or 
months,  pathologists  find  that  certain  structural  changes  have 
taken  place  in  the  cells,  changes  which  are  not  necessarily  per- 
manent or  irremediable,  but  none  the  less  pathologic  in  char- 
acter. If  by  functional  diseases  were  meant  those  which  are 
usually  curable  and  temporary,  and  by  organic  diseases  those 
which  are  incurable  and,  therefore,  permanent,  there  would  be 
more  reason  for  such  a  classification;  but  no  such  significance 
ran  now  be  attached  to  these  terms,  since  it  has  been  well 
established  that  resolution  can  occur  in  inflamed  tissues  and 
that  degenerated  cells  sometimes  undergo  regeneration.  In 
other  words,  organic  diseases  are  sometimes  curable;  and,  on 
the  other  hand,  certain  affections  which  have  been  generally 
classed  among  the  functional  disorders  are  comparatively  sel- 
dom completely  cured. 

There  does  not  seem,  thus,  to  be  any  good  reason  for  retain- 
ing longer  the  time-honored  division  of  diseases  into  functional 
and  organic.  It  is  confusing,  misleading,  and  serves  no  good 
purpose.  A  better  classification  for  the  so-called  functional 
disorders  would  be  under  the  title,  Diseases  Having  No 
Known  Anatomic  Basis. 

Then,  in  placing  certain  gastro-intestinal  derangements 
under  the  head  of  neuroses,  as  must  be  done  for  the  present, 


374  THE    GASTRO-INTESTINAL    CLINIC 

we  should  clearly  explain  that  by  such  a  classification  we 
merely  express  our  ignorance  of  their  actual  causes  or  of  the 
lesions  upon  which  they  really  depend,  though  some  of  them 
are  known  to  be  manifestation  of  actual  disease  in  the  nervous 
system.  I  agree  in  the  main  with  Riegel  who,  in  this  connec- 
tion, says  ■} 

"  Are  we  justified  in  separating  all  functional  disorders  of 
the  stomach,  all  forms  of  dyspepsia,  into  those  diseases  that  are 
based  on  some  tangible  anatomic  lesions  of  the  organ  and  those 
that  are  purely  functional  in  character?  Is  it  correct  to  desig- 
nate the  latter  class  as  neuroses?  I  believe  that  a  division  of 
this  character  goes  altogether  too  far;  however  desirable  it 
may  be  to  have  an  anatomic  basis  for  every  disturbance  of 
function,  we  cannot  say  that  we  possess  such  a  basis  for  the 
present  in  a  large  number  of  functional  diseases  of  the  stom- 
ach ;  at  the  same  time  it  does  not  appear  to  me  that  we  are  justi- 
fied in  designating  the  latter  class  of  disturbances  neuroses, 
because  we  have  not  so  far  discovered  the  lesions  of  the  stom- 
ach that  cause  them. 

"  We  are  hardly  justified  in  calling  a  disease  a  nervous  dis- 
order because  pathologic-anatomic  changes  are  absent,  or, 
better,  because  we  cannot  find  them ;  more  is  needed,  we  should 
be  able  to  demonstrate  and  to  prove  that  these  functional  disor- 
ders are  really  caused  by  hyperstimulation  or  inhibition." 

Riegel,  it  will  be  observed,  while  still  finding  it  convenient  to 
designate  as  functional  the  lighter  or  more  obscure  affections 
for  which  we  cannot  demonstrate  an  anatomic  cause  or  lesion, 
plainly  considers  that  some  such  lesion  exists  even  though  we 
cannot  find  it.  I  would,  therefore,  paraphrase  one  of  the 
sentences  quoted  above  from  Riegel  to  read  thus :  "  We  are 
hardly  justified  in  calling  a  disease  a  functional  disorder 
because  pathologic-anatomic  changes  are  absent,  or  better, 
because  we  cannot  find  them." 

But,  while  tliere  probably  are  no  diseases  which  involve  ex- 

■•  "  Diseases  of    the    Stomach,"  by   Franz    Riegel,  Philadelphia,  etc., 
W.  B.  Saunders  &  Co.,  1903,  p.  291. 


THE*  CLASSIFICATION    OF    DISEASES  375 

clusively  functions  and  not  at  all  the  organs  by  which  the  func- 
tions are  performed — that  is  none  that  may  properly  be  called 
functional  disease  only — there  are  doubtless  many  affections 
of  the  gastro-intestinal  tract  which  may  with  strict  propriety 
be  called  nervous,  because  they  are  either  symptoms  of  disease 
in  the  nerve  centers  or  elsewhere  in  the  nervous  system 
or  else  they  are  reflected  from  morbid  conditions  in  some  other 
part  and  only  show  themselves  in  the  regions  mentioned  because 
of  the  heightened  reflexes  which  a  diseased  nervous  system 
produces.  This  is  especially  likely  to  occur  in  hysteria  or 
neurasthenia. 

Another  difficulty  in  arriving  at  a  satisfactory  classification 
of  the  diseases  under  consideration  is  the  fact  that  inherited 
or  acquired  weakness  of  the  nervous  system  is  constantly  ob- 
served as  a  complication  of  the  familiar  diseases  of  undoubted 
organic  character  such  as  ulcer,  cancer,  etc.  In  consequence 
we  rarely  encounter  a  clinical  picture  that  is  not  more  or  less 
complicated  with  nervous  features.  An  inherited  neurasthenic 
tendency  predisposes  to  displacements  and  constipation,  while 
these  help  to  develop  nervous  trouble  or  increase  an  already 
existing  neurasthenia  and  thus  things  tend  to  go  on  from  bad 
to  worse  in  a  vicious  circle.  Again  certain  persons  have  been 
endowed  from  birth  with  a  neurotic  tendency  to  overeat  and 
to  eat  too  fast  for  adequate  mastication.  Naturally  they 
easily  fall  victims  to  one  or  more  of  a  whole  series  of  affections 
such  as  hyperchlorhydria,  acid  gastric  catarrh,  ulcer,  constipa- 
tion, diarrhea,  dilatation  or  displacement  of  the  stomach,  etc., 
some  of  which  are  usually  classed  among  the  neuroses,  some 
among  functional  disorders,  and  others  among  the  organic 
diseases,  and  yet  types  of  each  class  may  often  coexist  in  such  a 
case.  Frequently  it  is  the  nervous  complications  of  the  dis- 
eases causing  real  tissue  changes  which  determine  the  symp- 
toms. I  have  seen  a  number  of  cases  in  which  a  pronounced 
chronic  gastritis  has  existed  for  years  without  producing  any 
discomfort,  because  there  did  not  happen  to  be  any  nervous 
complications,  and  the  patients,  but  for  a  persistently  furred 


n^  THE    GASTRO-INTESTINAL    CLINIC 

tongue,  or  some  eruption  on  the  skin,  considered  themselves 
well. 

*A11  that  can  be  done,  then,  is  to  designate  with  appropriate 
names  the  principal  groups  of  symptoms  or  pathologic  condi- 
tions and  describe  these  to  you  as  clearly  as  possible,  cautioning 
you  at  the  same  .time  that  you  must  not  expect  often  to  find 
them  simple  and  uncomplicated,  but  most  frequentl}^  inex- 
tricably mingled  with  symptoms  of  a  weakened  or  otherwise 
diseased  nervous  system  and  at  times  with  morbid  states  in 
other  parts.  Furthermore  you  should  bear  in  mind  that  while 
some  of  the  diseases  which,  for  want  of  fuller  knowledge,  are 
classed  among  the  neuroses,  are  really  nervous  affections, 
others  are  either  reflexes  from  diseases  elsewhere  in  the  body 
or  dependent  upon  lesions  not  discoverable,  or  at  least  not  yet 
discovered. 

Diseases  of  the  Stomach  and  Intestines  not  always  Separa- 
ble.— In  another  respect  I  have  found  it  convenient  to  depart 
from  the  conventional  rule  of  authors  to  consider  the  diseases 
of  the  stomach  exclusively  in  one  part  of  their  works,  and 
diseases  of  the  intestines  exclusively  in  another — often  in  a 
separate  volume.  Nature  has  not  separated  the  affections  of 
these  different  segments  of  the  alimentary  tube  by  any  such 
marked  differences  as  to  render  this  necessaiy,  and  it  has  seemed 
to  me  more  natural  and  logical  to  discuss  ulcer  of  the  duode- 
num in  the  lecture  directly  following  that  in  which  ulcer  of  the 
stomach  is  considered,  since  the  peptic  ulcer  constitutes  practi- 
cally the  same  disease  whether  it  occurs  in  the  stomach  or  in 
the  duodenum.  Then,  having  taken  up  the  consideration  of 
the  subject  of  ulceration,  it  is  more  convenient  and  natural  to 
continue  with  the  same  subject  and  proceed  with  the  discussion 
of  other  ulcers  of  the  intestines  in  the  succeeding  lectures,  than 
it  would  be  to  postpone  this  to  a  later  part  of  the  book.  Then, 
again,  it  has  been  more  convenient  to  consider  together  in  one 
lecture  the  subject  of  syphilis  of  the  stomach  and  intestines 
and  in  another  separate  one  the  subject  of  tuberculous  ulcera- 
tions of  the  stomach  and  intestines,  in  a  book  covering  so  much 


THE    CLASSIFICATION    OF    DISEASES  .     377 

ground  within  so  small  a  space  as  this  one  essays  to  do.  I 
regret  that  it  has  not  been  practicable  also,  without  doing 
violence  otherwise  to  the  most  natural  sequence  of  the  chapters, 
to  consider  the  catarrhal  inflammations  of  the  duodenum  and 
small  intestine  generally  directly  after  the  discussion  of  such 
inflammations  of  the  stomach,  since  they  are  closely  allied  and 
catarrh  of  the  stomach  probably  rarely  exists  without  the  co- 
existence of  a  similar  process  in  the  duodenum. 


LECTURE  XXXVI 

GASTRIC  ATONY,  OR  MYASTHENIA  GAS- 
TRICA  (MOTOR  INSUFFICIENCY,  ME- 
CHANICAL INSUFFICIENCY) 

Under  the  head  of  Gastric  Atony  I  shall  describe  to  you 
that  condition  "in  which  the  muscular  layers  of  the  stomach 
walls  have  become  abnormally  weakened  and  unable  on  this 
account  to  empty  the  viscus  within  the  usual  time.  Many 
names  have  been  suggested  for  the  condition,  some  of  which 
seem  to  me  quite  inappropriate,  and  the  multiplication  of  names 
for  it  still  goes  on  with  much  resulting  confusion  for  students 
of  the  subject.  Names  for  pathologic  conditions  or  groups 
of  symptoms  which  are  frequently  met  with,  even  though 
devoid  of  a  known  pathologic  basis,  first  of  all  should 
designate  the  condition  as  accurately  as  possible  and,  with  this 
requirement  fulfilled,  the  simpler  and  more  familiar  the  term 
the  better.  The  old  term  gastric  atony  or  atony  of  the  stomach 
expressed  a  very  definite  idea,  that  of  a  flabby  weakened  condi- 
tion of  the  motor  apparatus  of  the  stomach,  which  prevented  its 
being  emptied  as  quickly  as  normally  it  should  be.  It  is  closely 
allied  to  the  conception  of  gastric  dilatation  or  gastrectasis 
because  in  both  the  stomach  walls  are  weak  and  flabby,  with 
usually  a  marked  splashing  sound  to  be  elicited  at  almost  any 
time  during  the  day.  The  chief  difference  between  these  two 
conditions  is  the  fact  that  in  simple  atony  the  stomach  is  merely 
weak  but  not  enlarged,  v^^hereas  in  dilatation  it  is  weak  and 
enlarged  both.  But  there  is  an  entirely  different  condition  in 
which  the  stomach  is  unable  to  empty  itself  within  the  normal 
time  for  the  reason  that  there  exists  an  obstruction  at  its  out- 
let.    There  is  in  these  cases  often  for  a  long  time  no  weakness 

378 


GASTRIC    ATONY  379 

of  any  kind  in  the  stomach,  but,  on  the  contrary,  at  first  just  the 
opposite  as  a  rule,  the  muscular  walls  developing  an  exceptional 
degree  of  thickness  and  strength  in  the  effort  to  overcome  the 
obstruction.  The  only  things  in  common  between  these  two 
opposite  conditions  are  the  circumstances  that  in  both  the 
stomach  is  abnormally  long  in  emptying  itself  and  the  hyper- 
trophy which  usually  results  primarily  from  a  persistent  ob- 
struction of  the  pylorus  eventually  passes  over  into  atony  and 
then  finally  into  an  overstretching  of  the  stomach  walls.  Both 
gastric  atony  from  nervous  or  other  constitutional  cause  and 
pyloric  obstruction  thus  tend  at  last  to  develop  into  dilatation — 
gastrectasis.  Several  recent  authors,  including  Boas,  Riegel, 
and  others,  insist  that  these  two  opposite  conditions  of  gastric 
weakness  and  excessive  gastric  strength  should  be  considered 
together  under  a  single  name  and  hence  the  suggestion  of 
various  new  terms  such  as  Muscular  Insufficiency,  Mechanical 
Insufficiency,  etc.,  having  regard  to  the  inability  of  the  stomach 
in  both  to  get  rid  of  its  contents  in  the  usual  time. 

It  seems  to  me,  however,  simpler,  less  confusing,  and  better 
every  way  to  adhere  to  the  old  name  Gastric  Atony  for  the  very 
definite  condition  of  motor  weakness  in  the  stomach,  and 
designate  the  condition  of  excessive  strength  of  the  stomach 
walls  developed  in  the  effort  of  the  viscus  to  overcome  an 
obstruction,  by  a  different  name  which  should  be  based  upon 
its  aetiology  and  pathology.  Thus,  if  we  call  the  latter  condi- 
tion Pyloric  Obstruction,  we  have  a  name  which  does  not  need 
to  be  explained  or  defended  and  at  the  same  time  one  which 
accurately  defines  it.  The  chief  symptoms  of  Gastric  Atony 
and  of  Pyloric  Obstruction  in  its  earlier  stage  before  the  thick 
wall  weakens  or  dilatation  occurs,  are  not  the  same,  but 
very  unlike,  and  the  methods  of  treatment  must  be  different. 
Why  then  confuse  by  our  nomenclature  such  different 
entities  ? 

Relative  Importance  of  Atony,  Dilatation,  etc. — By  giving 
Gastric  Atony  and  the  allied  conditions,  Gastric  Dilatation  and 
the  displacements  of  the  abdominal  organs,  the  first  place  in 


380  THE    GASTRO-INTESTINAL    CLINIC 

those  of  these  lectures  which  are  devoted  to  the  consideration 
of  the  diagnosis  and  treatment  of  the  various  diseases  of  the 
■stomach  and  intestines,  I  desire  to  impress  upon  you  particu- 
larly their  great  relative  importance.  Too  often  physicians 
fancy  that  the  main  thing  in  regard  to  a  doubtful  stomach  is 
to  ascertain  how  much  HCl  it  secretes,  which  cannot  be  surely 
determined  without  the  introduction  of  a  tube,  and  certain 
chemical  processes  which  involve  some  sort  of  a  laboratory  and 
chemical  training,  while  the  results,  though  very  important  in 
many  cases,  are  much  less  so  as  a  rule  than  the  determination 
of  the  motor  power  of  the  stomach,  which  it  has  already 
been  shown,  in  Lecture  VI.,  can  be  done  in  nearly  all  cases 
within  a  few  minutes  by  an  external  examination,  with- 
out having  to  introduce  any  kind  of  instrument  into  the 
stomach. 

Many  patients  continue  to  enjoy  fair  health  in  spite  of  hav- 
ing a  moderate  excess  of  HCl  constantly  secreted  and  others, 
with  a  marked  deficiency,  or  even  a  total  lack  of  the  same, 
often  manage  to  get  on  without  serious  indisposition  so  long 
as  they  live  very  carefully ;  but  the  person  wdiose  stomach  can- 
not get  rid  of  a  hearty  dinner  within  seven  hours,  by  passing 
it  on  into  the  duodenum,  is  always  more  or  less  of  an  invalid, 
and  when  his  stomach  does  not  habitually  empty  itself  within 
each  twenty-four  hours,  he  is  a  sick  man  who  urgently  requires 
help,  either  medical  or  surgical,  if  he  is  to  be  prevented  from 
more  or  less  rapidly  succumbing  to  his  malady,  and  this  quite 
regardless  of  whether  his  stomach  secretes  an  excess  or  a  defi- 
ciency of  gastric  juice. 

Various  Degrees  o£  Atony. — There  may  be  various  degrees 
of  gastric  atony,  and  it  is  not  necessary  to  limit  the  term  arbi- 
trarily to  the  state  of  weakness  which  prevents  the  viscus  from 
emptying  itself  within  seven  hours  after  a  dinner,  as  Leube 
and  others  do.  The  constant  inability  to  accomplish  this 
implies  a  decided  grade  of  atony — a  sufficient  impairment  of 
the  motor  power  to  injure  the  health  quite  materially,  though 
less,  of  course,  than  that  degree  of  atony  which  shows  regularly 


GASTRIC    ATONY  38 1 

some  remains  of  food  in  the  stomach  in  the  morning  before 
breakfast  has  been  taken.  Indeed,  whenever  there  is  regularly 
experienced  a  feeling  of  weight  or  heaviness  in  the  stomach 
after  a  full  meal,  and  a  splashing  sound  is  obtainable  at  almost 
any  time  during  the  day  by  tapping  over  the  stomach,  you  will 
be  safe  in  diagnosing  some  degree  of  muscular  atony,  though 
these  in  any  given  case  may  possibly  be  symptoms  of  the  graver 
condition  of  dilatation  into  which  the  atony  has  already  devel-' 
oped.  In  the  latter  case,  however,  enlargement,  as  well  as 
weakness  of  the  stomach,  can  be  made  out  by  a  suitable  exam- 
ination, even  a  merely  external  one. 

Etiology. — Atony  of  the  stomach  is  one  of  the  most  frequent 
results  of  our  modern  high-pressure  mode  of  living.  All  the 
prevalent  faults  of  hygiene,  such  as  immoderate  eating,  ex- 
cesses i)i  vino  and  in  venery,  overwork,  especially  mental  over- 
work, deficient  sleep,  and  a  lack  of  pure  air  and  of  exercise  out 
of  doors,  predispose  to  this  condition.  Whatever  tends  to 
cause  neurasthenia  will  be  equally  efficient  in  producing  gastric 
atony,  which,  indeed^  is  a  very  frequent  accompaniment  of 
neurasthenia.  Typhoid  or  malarial  fever  and  tuberculosis 
markedly  favor  its  development,  as  do  also  the  severer  cases  of 
gastric  catarrh,  even  in  the  asthenic  form.  Sthenic,  or  acid 
gastric  catarrh,  as  well  as  a  severe  hyperchlorhydria,  often 
causes  spasm  of  the  pylorus,  with  a  resulting  obstruction  of  the 
outlet,  which,  as  in  the  case  of  cancer  or  other  tumor  in  the 
pylorus  or  duodenum,  or  a  mechanical  obstruction  of  any  kind 
in  the  same  region,  after  a  primary  strengthening  or  hypertro- 
phy of  the  stomach  walls,  in  nearly  all  such  cases  finally  super- 
induces a  very  marked  degree  of  gastric  atony  and  dilatation, 
but  it  is  probable  that  in  most  of  these  cases  there  is  first  an 
enlargement  of  the  stomach,  due  to  muscular  overaction,  and 
that  then  atony  and  dilatation  both  result  secondarily.  This 
subject  will  be  considered  when  I  take  up  dilatation  of  the 
stomach. 

In  women  the  corset,  by  putting  the  abdomen  in  splints  and 
preventing  any  efficient  exercise  of  the  abdominal   muscles, 


382  THE  GASTRO-INTESTINAL  CLINIC 

powerfully  conduces  to  gastric  atony.  It  produces  a  most 
flabby  condition  of  the  abdominal  muscles,  thus  lessening  mark- 
edly the  external  supports  of  all  the  abdominal  viscera.  Sag- 
ging of  many  of  these  (splanchnoptosis)  naturally  follows,  and 
is  further  favored  by  the  constriction  of  the  waistband  and 
corset  above,  especially  the  old-fashioned  short  corset,  less  by 
the  long  straight-front  kind,  as  well  as  by  the  weight  of  the 
skirts.  The  latter  are  supported  only  by  the  prominence  over 
the  belly,  which  the  corsets  and  waistbands  have  helped  to  form 
by  forcing  the  viscera  downward  and  forward.  This  pro- 
tuberance, therefore,  is  made  up  generally  of  the  displaced 
stomach  and  intestines,  including,  in  some  cases,  one  or  both 
kidneys  as  well.  The  displaced  stomach  is  nearly  always  an 
atonic  one,  probably  as  a  result  of  its  disturbed  innervation, 
and,  indeed,  the  same  forces  just  described  often  directly  dilate 
it  by  dragging  down  the  greater  curvature,  while  the  other 
parts  of  it  remain  fixed.  The  tendency  to  atony,  with  its  secjuel 
dilatation,  and  also  to  displacement  of  the  stomach,  is  often 
inherited  from  one  or  both  parents. 

Symptomatology. — The  symptoms  of  gastric  atony  are 
those  usually  attributed  to  dyspepsia.  Indeed,  when  dyspepsia 
is  not  the  result  of  an  increased  or  lessened  gastric  secretion,  or 
of  catarrh,  ulcer,  or  cancer  of  the  stomach,  it  very  generally 
means  impaired  motility  or  gastric  atony — or  the  more  serious 
condition  of  dilatation.  Symptoms  in  these  cases  may  be 
wholly  wanting,  but  there  may  be  a  furred  tongue,  bad 
breath,  belching  of  much  gas  (or  possibly  flatulence  in  the 
bowels),  weight  or  heaviness  after  meals,  though  rarely  a  real 
pain,  constipation,  -headache,  disturbed  sleep.  Sometimes, 
though  as  a  rule  only  after  the  development  of  dilatation  and 
stagnation  of  the  food,  and  also  after  the  intestines  have  become 
secondarily  involved  by  a  catarrhal  process,  there  may  be  more 
severe  phenomena,  such  as  anaemia,  nervous  and  mental  de- 
pression, complete  loss  of  appetite,  much  physical  prostration, 
emaciation,  etc.  Generally,  however,  so  long  as  the  disease  is 
limited  to  a  moderate  atony  of  the  stomach,  the  patient,  though 


GASTRIC    ATONY  383 

complaining  much,  will  eat  and  sleep  fairly  well,  continue  to 
attend  to  usual  duties,  and  present  the  appearance  of  good,  if 
not  robust,  health. 

Diagnosis. — In  Lecture  VI.,  under  the  general  head  of  Meth- 
ods of  Examination,  I  have  described  a  convenient  method  of 
deciding  whether  gastric  atony  be  present  or  not,  as  well  as  the 
degree  of  it.  It  is  a  more  satisfactory  one  than  any  other  that 
does  not  require  the  introduction  of  a  tube.  The  same  subject 
was  gone  over  fully  in  an  article  entitled  Atony,  Dilatation, 
and  Displacements  of  the  Stomach,  which  I  contributed  to  the 
International  Medical  Annual  for  1900.  The  following  extract 
from  that  article  will  make  clear  several  of  the  more  practicable 
methods  of  diagnosticating  gastric  atony: 

"  Simple  Tests  of  Gastric  Motility. — If  the  patient  be  made 
to  uncover  the  abdomen  and  assume  the  supine  position  with 
the  legs  slightly  flexed,  a  few  taps  with  the  tips  of  the  fingers 
over  the  stomach  will  generally  reveal  a  marked  muscular 
atony,  when  present,  by  the  splashing  sound  which  is  pro- 
duced. Sometimes,'  in  consequence  of  extreme  tension  of  the 
abdominal  muscles,  this  splashing  sound  cannot  be  obtained 
even  when  the  stomach  contains  much  fluid  and  its  walls  are 
quite  weak.  In  such  a  case,  if,  while  the  examiner  presses  his 
fingers  against  the  lower  part  of  the  stomach,  the  patient  be 
induced  to  contract  voluntarily  and  repeatedly  his  diaphragm 
and  abdominal  muscles,  as  is  done  by  the  Oriental  muscle 
dancers,  the  splash  can  usually  be  produced,  or  at  least  any 
fluid  present  can  be  felt,  when  there  is  much  motor  insuffi- 
ciency. 

"  In  the  perfectly  normal  stomach  with  properly  strong  and 
resilient  muscles  and  not  prolapsed,  the  splash  cannot  be  evoked 
by  any  method,  even  directly  after  drinking.  The  louder  the 
splash,  the  larger  the  area  over  which  it  can  be  developed,  and 
the  longer  after  a  meal,  or  after  drinking  a  definite  quantity 
of  fluid,  it  can  be  recognized,  the  greater  the  motor  insuffi- 
ciency. When  it  can  be  heard  over  a  much  larger  area  than 
the  stomach  normally  covers,  the  atony  has  become  a  dilata- 


384  THE    GASTRO-INTESTINAL    CLINIC 

tion ;  when  heard  lower  than  normal,  there  may  be  only  a 
downward  displacement. 

"  The  writer  of  this  has  lately  described  a  more  accurate 
practical  method  by  which  any  physician  reasonably  well 
skilled  in  percussion  can  first  determine  the  boundaries  of  the 
stomach  by  percussion  over  it  when  empty,  and  again  after 
drinking  one  or  two  glasses  of  water  with  the  patient  in  differ- 
ent positions,  especially  recumbent  and  standing;  and  then, 
having  ascertained  the  size  and  position  of  the  viscus,  he  may 
easily  determine  its  relative  muscular  power  or  motility  by  the 
time  recjuired  to  empty  itself  after  test  meals.  Examinations 
of  the  abdomen  by  both  the  splash  and  percussion  in  the  two 
different  positions,  and  by  the  method  above  mentioned,  will 
readily  show  when  the  stomach  has  become  empty  by  the  dis- 
appearance of  the  splash  previously  obtained,  and  of  the  zone 
of  dullness  heard  over  the  lowest  part  of  the  stomach  on  per- 
cussion with  the  patient  .standing.  In  determining  the  bound- 
aries, the  results  are  more  positive  if  the  stomach  be  first 
inflated,  either  by  pumping  air  in  through  a  tube  or  by  having 
the  patient  take  a  small  teaspoonful  of  sodium  bicarbonate  dis- 
solved in  a  glass  of  water,  followed  by  30  drops  of  dilute  HCl 
in  half  a  glass  of  water. 

"  In  the  case  of  patients  accustomed  to  the  tube,  it  is  easier, 
for  the  physician  at  least,  to  introduce  that  instrument  at  dif- 
ferent periods  after  meals,  and  thus  learn  how  long  it  takes 
the  stomach  to  propel  its  contents  into  the  duodenum.  This  is 
Leube's  method  of  testing  the  motor  function." 

Ewald's  salol  test  was  formerly  much  used  to  determine  the 
motility  of  stomachs,  but  has  been  less  depended  upon  of  late, 
because  with  it  there  are  possible  sources  of  error;  yet  it  will 
usually  yield  approximately  correct  results.  It  is  described  in 
Lecture  VI. 

Treatment. — To  cure  simple  atony  of  the  stomach  it  is 
necessary,  first  of  all,  to  remove  the  cause.  If  the  patient  has 
eaten  or  drunk  immoderately,  he  must  stop  and  follow  rational 
dietetic  rules.    Faulty  modes  of  dress  must  be  abandoned.   Any 


GASTRIC  ATONY  385 

Other  palpable  transgressions  of  the  laws  of  health  must  then 
be  corrected.  If  a  condition  of  general  neurasthenia  exist, 
there  must  be  a  resort  to  the  usual  methods  of  overcoming  it  by 
rest  in  a  degree  suitable  to  the  needs  of  the  case,  regulated 
exercise  and  nutritious  feeding,  with  massage  and  electricity 
generally  as  well  as  locally  to  the  region  of  the  stomach. 
Direct  faradization  of  the  stomach  with  the  intragastric  elec- 
trode, as  described  in  the  lecture  on  the  Treatment  of  Chronic 
Sthenic  Gastritis  (Lecture  L.),  will  be  the  most  rapid  and 
efficient  means  usually  of  restoring  tone  to  the  weakened  gas- 
tric muscle.  Abdominal  massage  is  next  in  efhcacy,  except 
when  hyperchlorhydria  complicates.  When  there  is  any  excess 
of  HCl  in  the  gastric  juice,  massage  of  the  abdomen  needs  to 
be  avoided,  and  the  condition  must  be  vigorously  combated 
by  diet  and  by  administering-  alkalies  in  full  and  frequent  doses 
at  first,  with  smaller  ones  or  less  frequent  ones  later  to  main- 
tain the  effect;  and  in  such  a  case,  which  does  not  yield  soon 
to  medicines,  the  high-tension  faradic  current  may  be  admin- 
istered intragastrically  for  five  to  eight  minutes  every  other 
day.  This  will  often  succeed  in  stubborn  cases  which  are  not 
dependent  upon  ulcer  or  the  scar  of  one.  To  neglect  hyper- 
chlorhydria is  not  only  to  risk  the  development  of  gastric  ulcer 
and  other  serious  complications,  but  also  spasm  of  the  pylorus, 
with  a  resulting  dilatation  of  the  stomach.  Fuller  details  of 
the  treatment  applicable  both  to  the  severer  cases  of  gastric 
atony  and  to  dilatation  resulting  from  either  atony  or  hyper- 
acidity, are  given  in  Lecture  XXXIX. 


LECTURE  XXXVII 

DILATATION    OF    THE    STOMACH— (DILA- 
TATIO  VENTRICULI,  GASTRECTASIS) 

Several  distinguished  authors  decHne  to  give  a  place  in 
their  nomenclature  for  this  very  common  and  well-defined 
anatomic  disease.  They  do  not  deny  that  there  are  such  dis- 
eases as  dilatation  of  the  heart,  dilatation  of  the  esophagus, 
dilatation  of  the  intestines,  and  probably  dilatation  of  most  of 
the  other  hollow  organs,  but  when  the  stomach  is  affected  in 
the  same  way,  they  prefer  to  disregard  the  anatomic  condition 
and  classify  the  malady  according  to  one  of  its  causes,  such  as 
obstruction  of  the  pylorus  or  \veakness  of  the  stomach  walls 
(myasthenia  gastrica,  motor  or  mechanical  insufficiency),  or 
according  to  its  most  important  symptom,  stagnation — ischo- 
chymia.  I  freely  concede  that  there  is  some  force  in  their  con- 
tentions, but  nearly  every  innovator  in  this  respect  has  coined 
a  new  name  for  the  affection,  and  the  result,  besides  being  con- 
trary to  the  analogy  of  similar  lesions  elsewhere,  is  complicat- 
ing and  confusing.  Dilatation  of  the  stomach  is  easily  under- 
stood as  that  condition  in  which  the  viscus  is  both  weaker  in 
expulsive  power,  and  larger  than  the  average  normal  stomach, 
with  a  tendency  to  grow  worse  in  both  respects.  The  accuracy 
of  this  definition  is  in  no  way  lessened  by  the  fact  that  robust 
persons  who  eat  or  drink  excessively  may  acquire  stomachs 
of  extra-large  capacity,  going  on  to  enormous  size  in  some  in- 
stances, without  at  first  showing  any  impairment  of  their 
motor  powder  or  other  functions.  Such  enlarged  stomachs 
during  their  stage  of  hypertrophy  have  been  described  by 
Ewald  as  cases  of  megastria,  and  by  Boas  as  megalogastria. 
As  such  persons  are  usually  not  long-lived,  it  is  quite  possible 

386 


DILATATION    OF    THE    STOMACH  387 

that  most  of  them  may  die  before  the  stage  of  dilatation 
develops. 

Acute  Gastrectasis. — By  the  term  gastrectasis,  or  dilatation 
of  the  stomach,  is  usually  signified  a  chronic  or  persistent  form, 
which  is  rarely  fatal  except  by  gradually  undermining  the 
health  and  vigor  after  months  or  years.  Recently,  however, 
many  cases  of  what  are  called  usually  acute  dilatation  of  the 
stomach  have  been  reported.  Little  or  nothing  is  to  be  found 
in  most  text-books  and  treatises  upon  the  stomach  concerning 
this  form  of  disease.  Yet  it  is  doubtless  much  more  frequent 
than  has  been  supposed,  and  as  most  of  the  cases  so  far  reported 
have  proved  fatal,  it  is  important  to  bestow  some  attention 
upon  the  subject  in  this  connection. 

Until  very  recently,  the  diagnosis  was  rarely  made  before 
death,  it  having  remained  for  the  autopsy  to  demonstrate  the 
cause.  A  variety  of  hypotheses  has  been  put  forward  to 
account  for  the  sudden  supervention  of  such  a  dangerous  con- 
dition. It  has  occurred  most  frequently  as  either  a  sequel  of 
operations  upon  the  stomach  or  other  viscera,  or  as  a  complica- 
tion of  pneumonia,  or  of  one  of  the  acute  infectious  fevers. 
Some  writers  have  supposed  that  the  gastric  muscles  had  be- 
come suddenly  paralyzed,  others  that  there  was  a  spasm  of  the 
pylorus  as  a  result  of  hyperacidity.  It  is  noteworthy  that  numer- 
ous cases  carefully  studied  by  stomach  specialists,  including  two 
by  Friedenwald  of  Baltimore,^  had  an  enormous  secretion  of 
hyperacid  fluid.  Still  others  hold  that  there  must  have  been  a 
mechanical  obstruction  of  some  kind  either  at  the  pylorus,  or, 
which  seems  more  plausible,  since  the  duodenum  is  often  found 
to  have  shared  in  the  dilatation,  at  some  point  in  the  intestines 
below. 

It  is  very  probable  that  each  of  these  causes  may  be  occasion- 
ally efficient  in  producing  a  sudden  and  dangerous  dilatation, 
especially  under  the  conditions  named  above,  when  the  vital 
powers  have  been  seriously  weakened  by  infectious  disease  or 
the  shock  of  an  operation ;  also  that  in  dyspeptic  or  debilitated 
''  A7H.  Med.,  August  10,  igoi. 


388  THE    GASTRO-INTESTINAL    CLINIC 

persons  overloading  the  stomach  might  cause  it.  Those  of  you 
,who  have  followed  this  series  of  lectures  attentively  should  not 
have  much  difficulty  in  making  promptly  the  diagnosis  of  acute 
dilatation  of  the  stomach,  especially  after  the  further  consider- 
ation of  the  subject  of  gastric  dilatation  in  general,  given 
in  this  and  the  subsequent  lectures.  The  same  rules  apply  con- 
cerning both  the  diagnosis  and  treatment  of  the  acute  form  as 
in  the  case  of  the  chronic  form,  except  that  the  symptoms,  espe- 
cially the  prostration  and  later  the  vomiting,  are  more  urgent, 
the  pain,  distention,  and  tympany  usually  much  greater  than  in 
any  chronic  case,  however  marked  or  severe,  and  the  necessity 
for  frequent  and  thorough  evacuation  of  the  dilated  viscus  by 
lavage,  more  imperative.  An  early  recognition  of  the  con- 
dition, and  energetic  treatment  of  it  in  such  a  manner,  would 
probably  have  saved  a  majority  of  the  fatal  cases  hitherto 
reported,  though,  in  those  in  which  the  infection  and  prostra- 
tion were  extreme,  it  is  possible  enough  that  even  our  more 
efficient  modern  methods  of  combating  such  accidents  might 
have  failed. 

It  seems  scarcely  necessary  to  remind  you  not  to  permit  food, 
drink,  or  medicines  to  be  taken  by  the  mouth  in  acute  dilatation. 
Least  of  all  should  soups  or  other  excitants  to  the  gastric  glands 
be  ingested  in  these  cases,  since  there  is  likely  to  be  in  them 
a  hypersecretion  of  the  gastric  juice,  amounting  sometimes,  as 
in  Friedenwald's  cases,  to  a  gastrosuccorrhea. 

CHRONIC  DILATATION   OF  THE   STOMACH. 

The  .Etiology. — Since  these  lectures  are  designed  tO'  be  prac- 
tical lessons  on,  rather  than  exhaustive  expositions  of,  the  sub- 
jects discussed,  I  shall  teach  you,  regardless  of  the  endless  va- 
riety of  classifications  and  definitions  found  in  the  books,  that 
setiologically  there  are  two -main  kinds  of  chronic  dilatation  of 
the  stomach — ( i )  the  atonic,  and  (2)  the  obstructive.  The  lat- 
ter may  be  subdivided  again  into  (a)  those  in  which  the  obstruc- 
tion is  spasmodic,  which  probably  include  a  large  majority,  and 
(b)  those  in  which  it  is  mechanical.     The  mechanical  obstruc- 


DILATATION    OF    THE    STOMACH  389 

tion  may  result  from  any  of  the  following  conditions,  which 
are  named  as  nearly  as  possible  in  the  order  of  their  frequency : 
( I )  Round  peptic  ulcer,  or  the  cicatrix  of  one,  in  the  pylorus  or 
duodenum;  (2)  the  stenosing  form  of  chronic  gastritis,  involv- 
ing especially  the  pylorus;  (3)  cancer  of  the  pylorus  or  duo- 
denum; (4)  kinks,  or  sharp  flexures,  in  the  pyloric  end  of  the 
stomach  or  in  the  duodenum,  produced  by  a  displacement  of 
the  stomach,  or  by  adhesions  gluing  the  pylorus  or  duodenum 
to  adjacent  structures;  (5)  very  rarely  other  tumors  or  a  dis- 
placed right  kidney  occluding  the  outlet  of  the  stomach,  or  les- 
sening the  lumen  of  the  pylorus  or  of  the  gut  below  by  pressure 
from  without. 

The  strictl}^  atonic  dilatations,  in  which  neither  hyperacidity 
with  spasmodic  closure  of  the  pylorus,  nor  mechanical  obstruc- 
tion plays  any  part  in  the  aetiology,  are  probably  less  both  in 
frequency  and  in  extent,  as  a  rule,  than  those  depending  upon 
obstruction,  though  you  will  see  numerous  cases  in  women  in 
whom  the  corset  and  dragging  skirts  have  had  much  to  do  with 
the  causation  as  described  in  the  preceding  lecture  on  Gastric 
Atony.  I  have  found  dilatations  dependent  upon  an  excessive 
secretion  of  HCl  (hyperchlorhydria  and  acid  gastric  catarrh), 
exceedingly  common,  and  in  a  few  cases  the  dilatation  has 
seemed  to  result  from  an  excessive  organic  acidity  due  to 
fermentation. 

It  is  possible  that  a  certain  proportion  of  the  cases  in  which 
the  findings  are  dilatation  of  the  stomach  with  absence  of  free 
HCl,  stagnation  of  the  contents,  much  organic  acidity  from 
fermentation,  and  no  mechanical  obstruction  discoverable,  may 
have  been  due  to  excessive  eating  and  drinking,  which  first  pro- 
duced a  hypertrophy  of  the  organ,  followed  later  by  a  weaken- 
ing of  the  muscular  fibers  and  dilatation.  Other  powerfully 
predisposing  causes  of  atonic  stomach  walls,  and  thus  indi- 
rectly of  dilatation,  are  tuberculosis,  cancer,  gastroptosis,  and 
diseases  of  the  heart,  catarrh  of  the  stomach,  especially  in  the 
acid  form,  and  intestinal  catarrh,  disease  of  the  liver,  anaemia, 
.or  any  vice  of  nutrition  which  lowers  the  nerve  and  muscle 


390  THE    GASTRO-IXTESTIXAL    CLIXIC 

tone  generally.  You  should  not  forget  that  inheritance  also 
plays  an  important  role  in  the  tendency  to  gastrectasis.  The 
children  of  parents  thus  afflicted  do  not  often  escape  it,  accord- 
ing to  my  experience. 

Symptomatology. — The  symptoms  differ  much  in  the  vari- 
ous types.  In  the  mildest  atonic  form  in  which  there  are  motor 
insufficiency  and  overdistention  after  eating,  \Yith  little  enlarge- 
ment demonstrable  when  the  organ  is  empty,  the  only  symp- 
toms may  be  a  coated  tongue,  bad  taste  in  the  mouth,  a  feeling 
of  weight  in  the  epigastrium,  and  an  uncomfortable  fullness 
after  meals,  with  usually  considerable  flatulence  (especially 
shown  by  belching),  a  lessened  appetite  (though  exceptionally 
the  appetite  continues  good),  and  often  constipation,  headache, 
poor  sleep,  and  some  vague  impairment  of  the  general  health. 
When  the  cardiac  orifice  contracts  more  tightly  than  the  pyloric 
there  may  be  no  belching,  but  only  a  gradual  accumulation  of 
gas  in  the  bowels.  In  such  cases  both  the  stomach  and  bowels 
are  markedly  distended  and  tympanitic  for  many  hours  after 
each  meal.  The  bowels  in  such  a  case  are  often  uncomfortably 
distended  till  after  the  next  stool. 

In  the  hyperacid  form  of  dilatation  there  may  be  spasm  of 
the  pylorus  only,  with  the  cardia  not  tightly  closed,  when  there 
will  be  active  contractions  of  the  stomach,  accompanied  usually 
by  pain,  which  is  relieved  by  belching  of  gas  or  by  copious  vom- 
iting. When  in  this  form  of  dilatation  both  orifices  of  the 
stomach  remain  long  spasmodically  closed,  the  violent  and 
ineffectual  contractions  produce  severe  crampy  pains,  which 
are  often  not  relieved  until  a  large  dose  of  some  alkali  or  a 
decided  sedative  has  been  given  or  until  emesis  has  been  pro- 
duced. The  same  conditions  cause  rapid  exhaustion  and 
overstretching  of  the  muscular  coats  of  the  stomach,  resulting 
finally,  when  not  relieved,  in  considerable  dilatation' with  some- 
times stagnation. 

In  marked  dilatation,  fermentation  is  always  excessive, 
the  intestines  are  secondarily  irritated  and  often  infected. 
Constipation    may    then    become    obstinate,  with    all    its    in- 


DILATATION   OF   THE   STOMACH  39I 

jurious  consequences,  but  may  alternate  with  diarrhea;  and 
aniEmia  and  the  other  symptoms  of  auto-intoxication,  in- 
ckiding  mental  and  nervous  depression,  headache,  insomnia, 
weakness,  emaciation,  etc.,  are  likely  to  develop.  The  same 
cause,  pyloric  spasm  due  to  hyperchlorhydria  or  acid  gastric 
catarrh,  may  in  time  produce  what  is  called  dilatation  with 
retention,  a  term  applied  to  those  cases,  usually  severe,  in 
which  remains  of  food  are  found  in  the  stomach  in  the  morn- 
ing before  breakfast,  that  is,  ten  to  twelve  hours  after  the  last 
meal.  You  may  occasionally  encounter  such  a  retention,  even 
in  cases  of  rather  moderate  dilatation,  especially  when  the  pa- 
tient has  eaten  a  heartier  or  more  complicated  meal  than  usual, 
or  eaten  the  last  meal  of  the  day  when  exceptionally  tired  or 
worried.  When  the  stage  of  retention  has  been  reached,  the 
vomiting  becomes  characteristic,  occurring  every  two  or  three 
days,  and  bringing  up  often  several  pints  of  very  sour  and  most 
offensive  fermenting  masses  of  partly  digested  food.  Emacia- 
tion and  a  variable  degree  of  physical  weakness  usually 
show  themselves  by  this  time,  and  go  on  from  bad  to  worse 
in  cases  not  under  proper  treatment,  but  in  these  hyper- 
acid cases  a  vigorous  and  persistent  treatment  of  the  underly- 
ing condition  may  arrest  the  process  at  almost  any  stage,  and 
start  the  patient  on  a  long  and  toilsome  road,  which  will  finally 
lead,  if  persevered  in,  to  a  restoration  of  health. 

When  dilatation  has  resulted  from  any  mechanical  obstruc- 
tion of  the  stomach  outlet,  except  the  swallowing  of  a  foreign 
body,  there  are  not  likely  to  result  such  violent  spasmodic  pains 
as  may  follow  the  sudden  closure  of  both  orifices  from  the  irri- 
tation of  hyperacid  gastric  contents.  The  stenosis  of  the 
pylorus  may  develop  more  gradually,  and  thus  the  element  of 
spasm  be  absent  from  the  clinical  picture.  In  other  respects 
the  symptoms,  except  when  the  obstruction  is  caused  by 
a  malignant  growth,  are  much  the  same,  and  develop  as  in 
the  form  already  described,  though  the  course  is  usually  more 
steadily  downward  and  not  amenable  to  non-surgical  treat- 
ment, as  it  is  in  the  hyperacid  cases. 


39-  THE    GASTRO-INTESTINAL    CLINIC 

In  the  malignant  cases,   there  is  the  added  constitutional 
Infection  which  hastens  the  downward  course  and  begets  its 
^own  peculiar  cachexia,  usually  some  time  before  the  dilatation 
has  progressed  far  enough  to  produce  a  serious  auto-intoxica- 
tion from  the  stagnation  and  retention. 

In  all  the  severer  forms  of  dilatation  which  are  accompanied 
by  great  delay  in  emptying  the  stomach,  and  especially  by  copi- 
ous vomiting,  the  system  is  insufficiently  supplied  with  fluid, 
and,  in  consequence,  there  is  scanty  urine,  with  thirst  and  a  dry 
skin.  You  should  always  bear  in  mind  in  doubtful  afebrile 
cases,  accompanied  by  pronounced  scantiness  of  the  urine,  that 
you  may  be  dealing  with  dilatation  of  the  stomach,  and  proceed 
to  make  a  very  careful  examination  of  the  abdomen. 

Among  the  objective  symptoms,  or  physical  signs  of  gastric 
dilatation,  are  the  splashing  sound  which  is  nearly  always  to 
be  obtained  in  such  cases  by  a  light  tapping  with  the  fingers 
over  the  stomach,  or  by  succussion,  not  only  during  the  usual 
digestive  period  of  two  or  three  hours  after  a  light  meal,  such 
as  the  continental  breakfast,  or  six  to  seven  hours  after  the 
usual  mixed  meal,  such  as  a  dinner,  but  even  for  a  much  longer 
period  after  eating.  In  a  marked  case  of  dilatation  you  can 
usually  obtain  the  splash  at  any  time  after  breakfast  during  the 
entire  .day  and  evening,  though,  unless  there  is  retention,  no 
such  signs  of  fluid  remaining  in  the  stomach  should  be  discov- 
erable before  any  food  or  drink  has  been  taken  in  the  morning. 
When  there  is  only  slight  dilatation  of  the  stomach  with  strong 
or  spasmodically  contracted  abdominal  muscles,  the  splash  may 
be  elicited  only  by  causing  the  patient  to  make  sudden  volun- 
tary contractions  of  the  diaphragm  and  recti  muscles.  The 
signs  of  dilatation,  as  well  as  of  displacements  of  the  stomach, 
which  are  afforded  by  percussion  in  various  positions  of  the 
body  and  auscultatory  percussion  and  auscultatory  friction, 
were  fully  described  and  discussed  in  Lecture  V.  Some  fur- 
ther account  of  them  was  also  given  in  Lecture  XXXVI.,  on 
Gastric  Atony. 

By  the  administration  of  a  teaspoonful  of  sodium  bicar- 


DILATATION    OP  THE    STOMACH  393 

bonate  well  dissolved  in  water,  follow^ed  by  30  to  40  drops  of 
dilute  HCl,  or  a  large  half-teaspoonful  of  tartaric  acid  dis- 
solved in  half  a  glass  of  water,  you  will  be  able  to  inflate 
thoroughly  any  except  the  very  largest  dilated  stomach,  and 
with  these  it  is  safe  to  repeat  the  above  doses  within  a  few 
minutes.  Having  thus  produced  a  marked  tympany  over  the 
entire  stomach,  no  great  delicacy  in  percussion  is  required  to 
map  out  the  boundaries,  except  in  very  obese  persons,  and  these 
are  pretty  sure  not  to  have  seriously  dilated  stomachs,  though 
the  latter  are  often  simply  enlarged — hypertrophied.  To 
clinch  the  matter  you  should  always  note  carefully  the  area 
limits  of  tympany  on  percussion,  with  the  patient  recumbent. 
Then,  give  two  glasses  of  water  and  percuss  the  patient  while 
in  the  standing  position.  If  a  zone  of  positive  dullness  or  flat- 
ness now  appears  across  the  middle  or  even  lower  abdomen 
where  before  there  was  tympany,  and  you  can  elicit  a  splash 
there  where  there  was  none  before,  the  lower  line  of  the  dullness 
marks  the  lower  border  of  the  stomach,  especially  if  the  lowest 
limits  of  the  splash  coincide.  If  the  colon  should  be  full  and 
the  result,  therefore,  seem  in  doubt,  empty  it  by  a  copious 
enema,  or  by  physic,  and  test  in  the  same  way  again. 

Some  of  the  chemical  tests  of  gastric  motility,  such  as 
Ewald's  salol  test,  or  Klemperer's  oil  test,  may  be  employed 
to  confirm  the  results  of  percussion,  but  are  not  very  cer- 
tain, and  not  necessary.  Reliable  means  of  deciding  in 
very  doubtful  cases  as  to  the  position  of  the  boundaries 
are  the  instrumental  methods,  such  as  palpating  with  one 
hand  over  the  bared  abdomen,  the  tip  of  a  sound  introduced 
into  the  stomach ;  or,  better  yet,  palpating  in  the  same  way 
Turck's  revolving  sound — the  gyromele.  By  means  of  the 
latter,  especially,  one  w^ith  a  little  practice  can  easily  and  very 
certainly  outline  the  stomach.  There  remain  the  examination 
"f  the  organ  by  m«ans  of  the  Roentgen  rays — practicable  with 
the  aid  of  an  unusually  powerful  apparatus  only — after  causing 
the  patient  to  swallow  half  an  ounce  of  bismuth  in  emulsion,  on 
each  of  several  days  in  succession,  and  the  use  of  the  electric 


394  THE   GASTRO-INTESTINAL   CLINIC 

lamp  within  the  stomach,  which  is  feasible  enough  when  further 
confirmation  of  the  simpler  methods  is  necessary.  Bismuth 
has  been  proved  to  be  unsafe  in  enormous  doses  too  frequently 
repeated,  and  wdien  used  in  this  w^ay,  care  should  be  taken  to 
secure  thorough  bowel  movements  every  day.     See  page  88. 

COMPLICATIONS  AND    CONSEQUENCES   OF   GASTRIC 
DILATATION 

It  would  be  a  well-nigh  endless  task  to  enumerate  all  the 
possible  complications  and  consequences  of  gastrectasis,  espe- 
cially if  one  were  to  include  in  the  list  all  the  consequences  of 
the  diseased  conditions  upon  which  dilatation  of  the  stomach 
may  depend.  Hyperchlorhydria,  in  any  of  its  forms,  including 
acid  gastritis,  pyloric  ulcer,  pyloric  cancer,  and  other  obstruct- 
ive disease  of  the  pylorus,  as  well  as  diabetes  and  various 
acute  infective  diseases  which  can  cause  gastrectasis,  all  tend  to 
produce  at  the  same  time  other  derangements  of  the  health, 
and  all  of  these  that  occur  might  be  considered  in  a  sense  com- 
plications of  the  dilatation. 

Among  the  most  serious  of  the  complications  which  can 
result  from  a  neglected  gastrectasis,  through  the  fermentation 
and  putrefaction  of  the  long-retained  gastric  contents,  is  tetany, 
a  brief  account  of  which  will  be  found  below. 

Autotoxic  nephritis,  a  weakening  of  the  entire  muscular  sys- 
tem, including  the  heart,  insomnia,  neurasthenia,  and  nervous 
prostration  are  other  possible  complications  or  consequences  of 
the  autotoxsemia  which  may  be  superinduced  by  a  prolonged 
and  incurable  or  badly  treated  curable  form  of  dilatation  of 
the  stomach. 

Tetany. — In  many  and  various  forms  of  gastro-intestinal 
disease  associated  with  neurasthenia  and  anaemia,  you  will  find 
a  hyperexcitability  of  the  reflexes.  In  a  good  many  of  them 
the  patients  will  complain  of  being  awakened  out  of  sleep  by 
involuntary  twitchings  or  contractions  of  the  extremities — 
especially  the  legs.  Very  exceptionally,  indeed,  in  extreme 
dilatation  of  the  stomach  with  hyperchlorhydria  or  stenosis  of 


DILATATION  OF  THE  STOMACH  395 

the  pylorus,  there  occurs  what  is  called  tetany.  This  affection 
is  characterized  by  convulsive  attacks  in  which  there  are  spas- 
modic contractions  of  the  flexor  muscles  of  the  arms  and 
legs,  especially  the  calves.  The  abdominal  and  other  muscles 
may  also  be  involved,  and  there  is  often  during  the  attack  a 
peculiar  fixed  grimace  due  to  a  spasm  of  the  facial  muscles. 
Generally,  consciousness  is  not  lost,  but  there  is  frequently 
some  disturbance  of  the  speech,  and  occasionally  complete  un- 
consciousness. The  cases  thus  affected  are  difficult  to  diagnos- 
ticate from  true  epilepsy.  The  attacks  may  be  so  severe  in  rare 
cases  as  to  closely  resemble  tetanus  itself. 

It  is  now  generally  admitted  that  gastric  tetany  is  the  result 
of  an  auto-intoxication.  The  decomposing  stagnant  material 
in  the  stomach  poisons  the  blood  and  nerves,  so  that  the  slight- 
est exciting  cause  may  provoke,  an  attack.  In  not  a  few  in- 
stances attacks  of  the  kind  have  been  provoked  by  lavage 
of  the  stomach,  but  it  is  highly  probable  that  these  were 
neglected  and  aggravated  cases  that  could  not  have  recovered 
under  any  circumstances,  and  also  that  if  the  lavage  had  been 
begun  early  enough  and  carried  out  intelligently  at  the  proper 
time  with  the  aid  of  such  other  treatment,  medical,  mechan- 
ical, or  surgical,  as  was  required  for  the  dilatation,  there  would 
have  been  no  tetany,  and  that  in  many  of  these  cases  a  cure 
might  have  resulted.  The  therapy  of  gastric  tetany  is  consid- 
ered at  the  end  of  Lecture  XXXIX.,  in  the  Treatment  of  Dila- 
tation of  the  Stomach. 


LECTURE  XXXVIII 

THE    DIAGNOSIS    OF    DILATATION    OF 
THE    STOMACH 

When  a  stomach  has  once  become  decidedly  dilated,  from 
whatever  cause,  its  most  conspicuous  local  features  will  be  (i) 
an  enlargement  of  the  organ  beyond  the  usual  limits  of  the  nor- 
mal stomach;  (2)  slowness  and  often  incompleteness  in  pass- 
ing its  contents  on  into  the  duodenum;  (3)  a  flabbiness  or  re- 
laxed condition  of  the  stomach  walls,  as  shown  by  the  splashing 
sound  over  the  viscus,  elicited  in  various  ways  as  previously 
described,  and  by  the  lack  of  resistance  felt  on  palpating 
deeply  the  same  part  of  the  abdomen. 

Incidentally,  also,  there  will  be  increased  fermentation  of  the 
ingesta  with  much  gas,  which  may  show  itself  by  eructations 
or,  passing  downward,  produce  an  uncomfortable  distention  of 
the  intestines.  In  case  both  orifices  of  the  organ  are  spasmod- 
ically contracted,  the  stomach  itself  undergoes  marked  and 
more  or  less  painful  distention,  sometimes  so  much  so  that  it 
stands  out  prominentl}^,  and  its  size  and  location  can  then  be 
determined  upon  simple  inspection.  In  such  cases,  too,  there 
are  often  powerful  and  painful  contractions  of  the  stomach 
walls,  which  may  be  visible  externally.  In  dilatation  which  is 
at  all  marked,  the  percussion  note  over  the  stomach  is  nearly 
always  tympanitic,  so  that  it  is  not  usually  difficult  to  map 
out  its  boundaries,  even  without  artificial  inflation,  by  the  spe- 
cial method  described  in  Lecture  VI.  When  this  is  not  the 
case,  you  can  usually  succeed  in  inflating  it  sufficiently  by  the 
method  described  in  the  preceding  lecture. 

Many  authors  advise  inflating  by  pumping  air  in  through 
a  tube  which  is  first  introduced  in  the  usual  way,  and  this  is  a 

396 


DIAGNOSIS    OF    DILATATION    OF    STOMACH  ,         397 

very  good  method ;  but,  remembering  that  these  lectures  are  ad- 
dressed to  general  practitioners,  I  am  trying  to  teach  the  sim- 
plest methods  which  can  be  depended  on  to  effect  the  desired 
result.  The  tube  is  indispensable  in  determining  the  functional 
work  of  the  stomach  and  diagnosticating  the  diseases  of  its 
glands,  as  well  as  in  the  treatment  of  some  of  its  affections. 
No  intragastric  instrument,  however,  is  necessary,  except  in 
unusual  instances,  to  make  out  the  size  and  location  of  the 
stomach  with  sufficient  exactness  for  most  clinical  purposes, 
and  this  should  always  be  done  at  the  very  first  consultation 
with  a  dyspeptic,  when  to  insist  upon  introducing  a  tube 
immediately  would  often  prevent  any  subsequent  consulta- 
tions and  thus  result  in  a  loss  to  both  patient  and  physician. 
As  much  as  possible  should  be  learned  first  without  the  tube, 
and  the  importance  of  the  knowledge  thus  acquired,  especially 
if  gastric  dilatation  be  demonstrated  or  a  displacement  of  the 
stomach,  intestines,  liver,  or  kidneys  be  found,  assists  greatly  in 
reconciling  the  patient  to  less  agreeable  procedures  afterward ; 
and  one  or  more  of  these  faults  you  will  find,  as  a  rule,  in  fully 
one-third  to  one-half  of  your  chronically  ailing  women  patients. 

To  establish  the  diagnosis,  then,  of  dilatation  of  the  stom- 
ach you  must  (i)  demonstrate  an  enlargement  of  it,  and  (2) 
abnormal  weakness  in  its  walls.  The  normal  stomach  extends 
from  the  diaphragm  above,  at  the  left,  where  it  is  in  appo- 
sition with  the  heart,  to  a  point  in  the  middle  line  midway 
between  the  ensiform  process  of  the  sternum  and  the  umbilicus 
or  at  the  lowest  one  inch  above  the  latter,  and  from  the  anterior 
axillary  line,  at  the  left,  one  and  one-half  to  two  inches  to  the 
right  of  the  middle  line.  But  considerable  variations  in  the 
size  of  the  stomach  may  occur  normally.  In  Germany,  stom- 
achs seem  to  average  larger  than  elsewhere,  and  a  number  of 
German  writers  hold  that  one  not  extending  below  the  level 
of  the  umbilicus  is  not  abnormally  large ;  but  a  preponderance 
of  other  trustworthy  evidence  is  in  favor  of  the  dimensions 
above  given. 

The  accompanying   illustrations   represent   side  by   side   a 


398 


THE    GASTRO-IXTESTINAL    CLINIC 


normal  and  a  moderately  dilated  stomach.     Figure  51   is  an 
exact  reproduction  of  one  in  Fleiner's  Krankhcitcn  dev  Ver- 


FiG.  51. — Stomach  of  normal  size.  The  stomach,  normal  in  size  and 
position,  is  shown  by  the  dashed  line,  the  liver  to  the  right  and  partly 
covering  it.    The  shaded  part  is  that  in  contact  with  the  abdominal  wall. 

dauuiigsovganc,  and  Figure  52  is  the  same  with  the  stomach 
enlarged  downward  and  laterally,  as  it  most  commonly  is  in 
gastrectasis  of  a  not  very  high  grade.     In  the  cases  of  pyloric 


DIAGNOSIS    OF    DILATATION    OF    STOMACH  399 

tumors,  and  in  certain  atonic  cases,  a  much  more  extensive 
dilatation  may  result. 

Figure  51  shows  the  outlines  of  a  stomach  in  the  normal  posi- 


FiG.  52.— The  stomach  dilated,  but  not  displaced,  is  shown  by  the  dashed 

line. 

tion  and  of  the  average  size,  as  it  is  usually  found  in  a 
perfectly  healthy  young  person;  and  it  is  noteworthy  that  in 
middle  or  advanced  age,  especially  in  persons  who  have  in- 


400  THE    GASTRO-INTESTINAL    CLINIC 

diilged  excessively  in  either  food  or  drink,  the  stomach  is 
usually  larger  than. during  the  first  half  of  life.  The  shaded 
area  in  the  same  illustration  shows  that  part  of  the  stomach 
usually  in  contact  with  the  anterior  abdominal  wall  and  there- 
fore easily  percussed;  a  relatively  small  area,  you  will  notice. 
But  not  many  stomachs  of  normal  size  and  position  will  be 
met  with  among  dyspeptics.  The  lower  border  in  most  cases 
will  be  found  at  or  below  the  navel.  When  the  organ  has 
been  fully  inflated,  except  possibly  in  very  fat  persons,  the 
lesser  curvature  and  entire  fundus  can  be  made  out  by  careful 
percussion,  in  spite  of  the  overlying  structures. 

If  percussion  should  fail,  as  it  almost  never  does  in  skilled 
hands,  the  best  of  the  instrumental  aids  tO'  a  correct  diagnosis 
are  Turck's  gyromele  or  revolving  sound,  and  some  one  of  the 
forms  of  apparatus  by  means  of  which  the  interior  of  the  stom- 
ach is  dimly  illuminated  by  a  tiny  electric  light  on  the  end  of 
a  sound.  The  gyromele  affords  the  most  accurate  results,  since 
it  does  not  distend  the  organ  any,  nor  otherwise  mislead.  Its 
distal  end  can  easily  be  palpated,  as  it  wabbles  around  the 
outer  limits  of  the  viscus.  But  it  must  be  employed  cautiously, 
and  never  when  an  ulcer  or  cancer  is  likely  to  be  present.  Pa- 
tients like  it  even  less  than  they  do  the  tube.  Though  I  have  in 
my  office  a  number  of  such  ingenious  intragastric  instruments 
and  am  familiar  with  their  technique,  I  rarely  employ  them, 
having  never  yet  failed  to  learn  by  percussion  and  the  splash, 
with  sufficient  exactness  for  all  practical  purposes,  the  size  and 
position  of  the  stomach  after  inflating  it,  even  in  obese  patients. 

In  the  more  doubtful  cases,  the  aid  of  auscultatory  percus- 
sion and  auscultatory  friction  may  be  necessary ;  and  it  may  be 
as  well  to  repeat  here  that  in  any  case  of  decided  dilatation 
when  liquid  is  present  in  the  viscus,  a  splashing  sound  can  be 
obtained  usually  by  succussion,  or  by  clapotage  (abrupt  tapping 
over  it,  with  the  fingers  held  perpendicularly  to  the  abdomen). 
By  auscultating  with  the  help  of  a  binaural  stethoscope  to  as- 
certain over  how  large  a  region  the  splash  is  heard,  the  lower 
and  right  borders  of  the  stomach  can  be  approximately  deter- 


DIAGNOSIS    OF    DILATATION    OF    STOMACH 


401 


mined,  though  sometimes  the  splash  cannot  be  heard  within  an 
inch  or  two  of  the  lower  border  and  the  full  size  is  then  not 
revealed.    Percussion,  however,  corrects  this  finding. 

To  determine  the  second  indispensable  factor  in  gastric  dila- 
tation, to  wit,  deficient  motility  or  a  lack  of  propulsive  power 


Fig.  53. — Area  of  tympany  in  case  of  gastrectasis  with  gastroptosis. 

in  the  stomach,  the  surest  method  is  to  withdraw  the  contents 
with  the  help  of  a  tube  at  sufficient  intervals  after  eating — 
about  three  hours  after  a  light  carbohydrate  meal,  and  six  to 
seven  hours  after  a  large  mixed  meal,  such  as  a  dinner.  If  then 
the  stomach  be  found  empty,  there  is  no^  serious  lack  of  motor 
power,  but  if  much  liquid  or  remains  of  food  are  then  brought 
up,  the  propulsive  power  is  poor,  except,  of  course,  when  there 
is  obstruction  at  the  pylorus.  But  when  there  is  enlargement 
with  an  easily  obtained  splashing  sound,  dilatation  is  present, 
either  atonic  or  obstructive.  A  foamy,  yeasty  appearance  of 
the  contents  with  a  very  sour  or  rancid  odor  would  be  also 
confirmatory  evidence  of  dilatation  with  stagnation.  If  food 
remnants,  or  even  digested  chyme,  should  be  found  in  the 


402  THE    GASTRO-INTESTINAL    CLINIC 

stomach  before  breakfast,  it  would  show  dilatation  with  reten- 
tion. The  salol  test  will  give  you  results  usually  which  approx- 
imate correctness ;  and  by  a  further  development  of  the  external 
method  of  determining  the  boundaries,  I  have  learned  to  decide 
with  much  exactness  when  a  stomach  has  emptied  itself.  After 
having  once  fixed  the  location  of  the  greater  curvature,  it  is 
only  necessary  to  tap  for  the  splash  with  the  patient  recumbent, 
and  percuss  with  him  first  recumbent  and  then  standing  (espe- 
cially if  the  colon  has  been  previously  cleared),  to  decide 
positively  whether  or  not  the. stomach  is  substantially  empty. 
By  testing  thus  at  the  proper  intervals  after  meals,  the  motor 
power  can  be  judged.     (See  Lecture  VI.) 

Differential  Diagnosis. — Having  thus  settled  the  two  main 
points  as  above  described,  if  there  is  enlargement  with  mark- 
edly weakened  motor  power,  dilatation  exists ;  but  there  might 
possibly  be  present  also  gastroplegia,  or  paralysis  of  the 
stomach,  a  very  rare  condition,  which  you  may  never  encoun- 
ter. The  latter  comes  on  suddenly  and  usually  after  some 
severe  shock,  mental,  moral,  or  physical,  especially  after  an 
operation.  The  suddenness  of  the  onset  and  the  completeness 
of  the  retention  of  all  food  with  a  swelling  in  the  epigastrium 
would  be  diagnostic.  Megastria,  or  simple  hypertrophy  of  the 
stomach,  should  never  mislead  you,  since  in  this  disease, 
though  the  stomach  is  enlarged,  it  is  strong,  able  to  empty  itself 
in  the  proper  time,  and  no  marked  splashing  sound  is  obtain- 
able even  shortly  after  eating  or  drinking. 

Gastroptosis  alone,  or  downward  displacement  of  the  stom- 
ach simply,  would  be  distinguished  by  the  fact  that  the  fundus 
of  the  stomach  and  the  lesser  as  well  as  the  greater  curvature, 
would  be  found  too  low,  as  shown  by  moderately  strong  per- 
cussion after  full  inflation,  or  the  use  of  the  instrumental  meth- 
ods of  exploration  previously  described.  The  tympanitic  note 
could  not  then  be  heard  up  to  the  region  of  cardiac  dullness  as 
normally  it  should  be,  except  that  in  the  cases  of  displaced 
pyloric  end,  there  would  be  no  change  in  the  percussion  note 
over  the  fundus.     Furthermore,  unless  dilatation  should  com- 


I 


DIAGNOSIS    OF    DILATATION    OF    STOMACH  403 

plicate  the  displacement,  as  it  usually  does  sooner  or  later,  the 
signs  of  insufficient  propulsive  power  would  be  wanting. 

The  condition  most  likely  to  cause  confusion  is  that  form  of 
displacement  known  as  vertical  stomach,  in  which  the  supports 
of  the  pyloric  end  having  become  much  relaxed  and  elongated, 
it  drops  downward  and  swings  around  toward  the  left  until 
the  organ  is  almost  perpendicular  in  the  abdominal  cavity. 
Before  such  a  displaced  stomach  has  secondarily  dilated,  it 
could  not,  of  course,  show  the  motor  insufficiency  of  true  gas- 
trectasis,  and  even  after  such  a  development  you  should  be  able 
to  easily  distinguish  it  by  a  careful  percussion  laterally  after 
full  inflation.  The  narrowness  of  the  perpendicular  strip  of 
tympany  extending  down  into  the  pelvis  often,  with  a  splash 
generally  obtainable  over  the  same  peculiar  space  only,  is  quite 
striking.  I  lately  saw  three  such  cases  in  new  patients  during 
a  single  week. 

Reichmann's  disease,  in  which  there  is  a  continual  flow  of 
gastric  juice,  might  be  mistaken  foi  dilatation  if  occurring  in 
an  abnormally  large  stomach,  since  fluid  could  in  such  a  case  be 
found  in  the  organ  at  times  when  it  should  be  empty.  But  if 
you  wash  out  such  a  stomach  and  then  withhold  all  food  and 
drink  from  the  patient  for  half  a  day,  fluid  would  be  found 
present  at  the  end  of  that  time  in  Reichmann's  disease,  but  not 
in  dilatation.  Moreover,  in  the  latter  disease,  the  fluid  to  be 
obtained  from  the  fasting  stomach  or  before  breakfast  is  likely 
to  be  a  very  strong  gastric  juice  with  little  or  no  food  remains 
and  odorless,  while  in  dilatation  the  contents  are  malodorous, 
sour-smelling,  and  full  of  partly  digested  food  along  with 
abundant  fermentation  products. 

Hypertrophic  enlargement  of  the  stomach  without  dilatation 
might  also  deceive  you,  if  at  the  same  time  there  should  be 
such  an  excessive  secretion  of  HCl  (hyperchlorhydria)  as  to 
produce  spasm  of  the  pylorus  with  temporary  retention  of  the 
gastric  contents ;  or  the  same  kind  of  a  stomach  with  such  a 
deficiency  of  gastric  juice  (hypochlorhydria,  hypopepsia)  as 
to  prevent  the  digestion  of  the  gastric  contents,  might  mislead, 


404  THE    GASTRO-INTESTINAL    CLINIC 

since  in  this  case  the  contents  might  exceptionally  be  retained 
beyond  the  usual  time,  especially  if  meat  imperfectly  masti- 
eated  had  formed  part  of  the  food  taken.  In  both  these  cases, 
however,  emptying  the  stomach  with  a  tube,  and  a  chemical 
examination  of  the  contents  (in  the  case  of  marked  hypochlor- 
hydria  even  simple  inspection  should  suffice),  would  reveal  the 
true  cause  of  the  delayed  expulsion.  Moreover,  in  the  condi- 
tions supposed,  there  would  be  an  absence  of  the  splashing 
sound,  even  with  the  organ  partly  filled,  and  this  alone  would 
be  incompatible  with  much  muscular  atony — still  more  with 
marked  dilatation. 

Ewald  teaches  that  we  should  also  differentiate  gastric  dila- 
tation from  an  overdistended  colon,  ovarian  cysts,  sacculated 
ascites,  hydronephrosis,  and  echinococcus  cysts,  but  anyone 
who  has  learned  to  percuss  out  the  boundaries  of  the  stomach 
after  inflation  could  scarcely  be  misled  by  any  of  the  above- 
mentioned  diseases.  If,  however,  you  should  have  serious 
doubt  as  to  the  possible  presence  of  any  of  them,  the  use  of  the 
gyromele  in  the  stomach  would  enable  you  to  reach  a  positive 
decision.  In  all  doubtful  cases  the  examination  should  be 
begun  with  the  stomach  and  colon  both  empty.  You  can  then 
afterward  introduce  fluid  into  the  stomach  as  required. 


LECTURE  XXXIX 

TREATMENT  OF  DILATATION  OF  THE 
STOMACH 

Prognosis. — Gastrectasis,  resulting  from  a  mechanical  ob- 
struction of  the  pylorus,  has,  naturally,  the  same  prognosis  as 
its  cause.  When  this  is  the  cicatrix  of  a  healed  ulcer,  a  benign 
tumor  in  or  near  the  outlet,  the  pressure  of  a  displaced  right 
kidney,  inflammatory  adhesions  between  the  stomach  and  any 
adjacent  organ,  or  a  kinking  of  the  duodenum  from  a  down- 
ward displacement  of  the  stomach,  prompt  surgical  interven- 
tion may  often  effect  a  restoration  to  health ;  but  in  cases  due 
to  the  last-named  cause,  or  to  a  marked  displacement  of  the 
right  kidney,  a  resort  to  the  knife  is  rarely  necessary,  non- 
surgical measures  usually  sufficing,  if  skillfully  carried  out 
and  for  a  sufficient  length  of  time.  When  the  obstruction  is 
due  to  a  malignant  growth,  a  very  early  diagnosis,  followed  at 
once  by  a  removal  of  the  neoplasm,  may  rescue  the  patient ;  but 
under  present  prevalent  conditions  this  rarely  happens,  because 
the  diagnosis  is  nearly  always  made  too  late.  The  cases 
dependent  upon  hyperchlorhydria  and  the  atonic  cases  are 
amenable  to  treatment  by  dietetic,  medicinal,  and  mechanical 
means  when  taken  in  time,  but  unfortunately  are  rarely  recog- 
nized until  they  have  progressed  to  an  advanced  stage  and  the 
patient's  health  has  been  so  badly  undermined  that  the  recovery 
is  tedious  and  difficult. 

Treatment. — It  is  unnecessary  to  mention  here  the  indica- 
tions for  the  surgical  operations  when  a  cancer  or  other  tumor 
obstructs  the  pylorus,  producing  gastrectasis  and  threatening  a 
speedy  fatal  result,  since  these  are  more  appropriately  discussed 
in  Lecture  LXXXIL,  on  the  Surgery  of  the  Stomach  and  Intes- 

405 


406  THE    GASTRO-INTESTINAL    CLINIC 

tines.  The  other  mechanical  obstructions  calhng  for  surgical 
intervention  are  also  referred  to  briefly  in  the  same  place ;  besides 
-sthey  are  all  fully  described  in  the  works  on  surgery,  and  the 
general  practitioners  who  are  prepared  to  open  the  abdominal 
cavity  in  an  emergency  (as  all  of  you  should  be)  will  neces- 
sarily have  such  works  at  hand.  But  I  need  scarcely  add  that 
except  in  a  grave  emergency  admitting  of  no  delay,  you  should 
summon  the  most  expert  laparotomist  obtainable  to  perform 
such  delicate  operations. 

It  is  my  purpose  to  indicate  here  how  you  may  treat  hope- 
fully by  non-operative  measures  the  cases  of  dilatation  amenable 
to  such  treatment.  These  measures  comprise  diet,  lavage, 
abdominal  massage,  electricity,  gymnastics  of  the  trunk 
muscles,  a  few  medicinal  remedies,  and  all  the  means  by  which 
the  health  and  strength  of  the  patient  can  be  built  up,  includ- 
ing, in  addition  to  those  just  mentioned,  hydrotherapy,  climato- 
therapy,  a  judicious  alternation  of  rest  and  outdoor  exercise, 
etc. 

Dilatation  from  Pyloric  Spasm. — Let  us  consider  first  a 
most  important  class  of  what  may  be  called  the  non-surgical 
dilatations  of  the  stomach — to  wit,  those  dependent  upon  spasm 
of  the  pylorus  following  severe  and  generally  old  neglected 
cases  of  hyperchlorhydria  or  acid  gastric  catarrh.  These  are 
likely  to  be  stubborn,  because  nearly  always  accompanied  either 
as  cause  or  consequence  by  chronic  intestinal  indigestion  and 
often  by  intestinal  catarrh  with  neurasthenia  and  greatly 
lowered  nutrition.  The  diet,  which  is  most  important  in  all 
cases  of  dilatation,  is  especially  so  in  this  form  of  it  and  is 
different  from  that  required  for  simple  atonic  dilatation.  The 
articles  which  usually  agree  best  are  milk,  cream  and  butter, 
eggs,  stale  bread,  toasted  (but  not  too  hard,  and  not  the  coarsest 
kinds  of  bread,  which  are  too  irritating),  and  the  partly  dex- 
trinized  grain  foods  such  as  Shredded  Wheat  Biscuits,  Force, 
Grape  Nuts,  Malta  Vita,  etc.,  taken  dry  or  slightly  moistened 
with  milk  or  water,  purees  of  the  blander  vegetables,  Plasmon 
(a  valuable  new  proteid  made  from  milk),  olive  oil  and  other 


TREATMENT    OF    DILATATION    OF    STOMACH  40/ 

fats,  beef  juice,  and  often  finely  chopped  beef,  but  either  no 
meats  in  the  ordinary  form,  or  small  portions  of  them,  as  well 
as  of  fish  and  oysters ;  no  other  shellfish.  Nothing  irritating  or 
very  stimulating  to  the  gastric  glands  should  be  allowed,  and 
this  rules  out  entirely  the  condiments,  acids  and  acid  fruits,  in- 
cluding tomatoes,  and  renders  generally  undesirable  the  coarser 
kinds  of  breads,  of  cereals  and  of  vegetables,  coffee  and  tea, 
and  the  alcoholic  beverages  without  exception.  Recent  experi- 
ments have  shown  that  the  fats  and  sugar  are  especially 
efficacious  in  lessening  the  secretion  of  the  gastric  juice,  though 
they  are  often  contra-indicated  by  the  intestinal  complication. 
The  starch  foods,  except  when  partly  dextrinized,  are  difficult 
of  digestion  in  such  cases  and  must  be  very  thoroughly  in- 
salivated, as  can  best  be  done  with  the  dryer  forms  long 
masticated,  and  all  these  should  be  taken  very  early  in  a  meal — 
never  at  the  end  of  it.  Even  then,  in  bad  cases  it  is  well  to 
give  Taka  Diastase  or  some  other  good  diastatic  preparation 
with  such  foods,  or  just  before  meals  to  assist  in  converting  the 
starch. 

In  this,  as  in  all  the  forms  O'f  gastric  dilatation,  very  large 
meals  and  any  overloading  of  the  stomach  with  either  food  or 
drink  must  be  absolutely  prohibited.  Whether  only  two  or 
three  moderate  meals  or  a  greater  number  of  smaller  ones  at 
shorter  intervals  are  to  be  taken  daily  is  a  cjuestion  to  be  de- 
termined in  each  case  by  itself,  since  no  general  rule  will  apply 
to  all.  Sometimes  frec[uent  small  feedings  agree  well,  but 
less  time  is  then  left  for  the  debilitated  organ  to  rest  and 
recuperate  between,  so  that,  as  a  rule,  you  will  probably  find  the 
best  curative  results  to  follow  the  plan  of  giving  two  or  three 
times  a  day  a  moderate  amount  of  bland,  digestible  food  as 
concentrated  in  form  as  possible,  so  as  not  to  distend  unduly, 
and  then,  if  necessary  in  bad  cases  to  keep  the  nutrition  up 
to  the  proper  level,  you  may  have  additional  nourishment  ad- 
ministered by  enema  once,  twice,  or  oftener  daily.  The  al- 
lowance of  sufificient  liquid  with  each  meal  to  dilute  and  thus 
lessen  the  acidity  of  the  gastric  juice  will  often  assist  in  relax- 


408  THE    GASTRO-INTESTINAL    CLINIC 

ing  the  spasm  of  the  pylorus  and  thus  in  curing  the  dilatation; 
but  the  amount  of  liquid  taken  should  never  be  enough  to  over- 
distend  the  stomach. 

No  cases  are  so  difficult  to  diet  as  those  of  hyperchlorhydrics, 
whether  or  not  their  stomachs  happen  to  be  dilated.  In  the 
higher  classes  of  society  especially  strongly  seasoned,  stimulat- 
ing proteid  viands  usually  predominate  in  the  daily  diet. 
Caterers,  cooks,  and  waiters  all  seem  in  a  conspiracy  to  force 
on  hyperchloriiydric  patients  foods  and  drinks  prepared  so  as  to 
suit  especially  atonic  stomachs,  and  therefore  injuriously  irri- 
tating for  the  opposite  kind.  Then,  if,  after  indulging  liberally 
in  the  customary  stimulating  foods  and  beverages,  such  a 
patient  suffers  from  burning  pains,  as  he  is  very  apt  to  do,  the 
trouble  is  often  aggravated  instead  of  relieved  by  the  treatment 
prescribed.  Whether  he  tries  some  quack  medicine,  consults 
the  drug-store  man,  or  calls  in  a  .physician  who  knows  only  one 
form  of  dyspepsia,  the  chances  are  that  the  remedy  depended 
upon  will  be  a  combination  of  ginger  or  capsicum  with  pepsin 
and  a  bitter  tonic,  and  often  full  doses  are  added  of  the  very 
drug  from  an  excess  of  which  he  is  suffering — that  is,  hydro- 
chloric acid. 

Medicines,  especially  alkalies  and  antispasmodics,  will 
usually  be  required  in  the  cases  of  dilatation  dependent  upon 
hyperchlorhydria,  and  you  may  administer  bicarbonate  of 
sodium  in  half-teaspoonful,  or  even  one-  or  two-teaspoonful, 
doses  two  hours  after  meals,  or  prepared  chalk  instead  when 
there  is  diarrhea,  or  calcined  magnesia  when  there  is  constipa- 
tion. Atropine  sulphate,  grns.  g^ir  to  -jV  several  times  a  day, 
may  be  needed  also  in  the  worst  cases  to  control  the  excessive 
secretion,  and  I  have  found  that  the  addition  of  3  to  4  grns.  of 
extract  of  yerba  santa  to  a  pill  containing  atropine  or  bella- 
donna and  nitrate  of  silver,  grn.  ^,  tends  to  the  production  of 
more  prompt  results.  But  many  of  these  cases  resist  both  diet 
and  the  strongest  medication  for  some  timiC,  and  here  intra- 
gastric faradization  with  the  current  of  high  tension  will  prove 
the  most  effective  of  any  means  at  our  command,  except  when 


TREATMENT  OF  DILATATION  OF  STOMACH  409 

the  hyperchlorhydria  is  due  to  a  latent  ulcer,  or  possibly  when 
perigastric  adhesions  complicate.  It  serves  at  once  to  increase 
muscular  contractions  and  diminish  secretion,  as  fully  ex- 
plained in  Lecture  L.  on  the  Treatment  of  Acid  Gastric 
Catarrh.  Massage  of  the  abdomen  is  contra-indicated  in  all 
cases  of  excessive  HCl.  The  necessity  for  mental  and  sexual 
rest  cannot  be  too  strongly  insisted  upon.  The  excessive 
HCl  secretion  sometimes  causes  an  intolerable  gastralgia, 
but  in  such  cases  opium  and  morphine  should  be  avoided,  as 
tending  to  increase  gastric  secretion  according  to  recent  ex- 
periments. Administer  instead  very  large  doses  of  alkalies 
with  atropine  either  hypodermically  or  by  the  mouth,  dissolved 
in  warm,  not  hot  water,  after  emptying  the  stomach  by  lavage. 
This  may  be  followed,  when  necessary  for  stubborn  pain,  by 
a  spray  of  menthol  or  cocaine,  one  grain  to  the  ounce,  applied 
inside  the  stomach  by  the  Einhorn  spray  apparatus.  Gym- 
nastic exercises  designed  to  strengthen  the  abdominal  and 
trunk  muscles  generally  assist  greatly  also  in  toning  up  the 
musculature  of  the  stomach  itself,  when  the  hyperacidity  has 
been  controlled  by  the  means  already  discussed. 

Intragastric  Electricity — But  electricity  is  the  prince  of 
remedies  in  these  cases  of  dilatation  associated  with,  and  often 
dependent  upon,  an  excessive  secretion  of  HCl.  Large  doses 
applied  percutaneously  through  from  the  spine  to  the  stomach 
can  often  help  decidedly,  as  many  observers  have  testified,  but 
with  nothing  like  the  certainty  and  rapidity  of  effects  obtain- 
able by  the  high-tension  induced  current  (faradism),  applied 
with  one  pole  within  the  stomach  and  the  other  either  on  the 
spine  or  over  the  epigastrium.  The  technique  of  such  applica- 
tions is  fully  described  in  Lecture  XXX.,  under  Methods  of 
Treatment.  Let  me  add  here,  however,  that  with  a  suitable 
electrode  such  as  my  modification  of  Einhorn's,  the  procedure 
is  not  difficult  nor  troublesome,  except  for  patients  who  have 
an  irritable  stomach.  (See  page  330  for  several  other  im- 
portant contra-indications).  Any  form  of  instrument  will  an- 
swer which  carries  the  current  into  the  water  with  which  the 


4IO  THE    GASTRO-INTESTINAL    CLINIC 

stomach  must  be  partly  filled,  this  water  really  acting  as  the  in- 
tragastric electrode  and  distributing  the  current  very  gently 
to  all  those  parts  of  the  viscus  with  which  it  is  in  contact. 
But  the  smaller  this  current-carrier  is  the  better,  provided  it  has 
sufficient  rigidity  to  be  easily  introduced.  It  is  usually  best  to 
have  the  stomach  empty  when  electricity  is  given  in  this  way, 
especially  if  the  stomach  is  inclined  to  be  irritable,  and  in  the 
latter  case,  it  is  sometimes  necessary  to  wash  out  before  begin- 
ning the  treatment.  No  method  so  certainly  tones  up  the  weak- 
ened gastric  muscles,  and  at  the  same  time  it  sooner  or  later 
lessens  the  excessive  secretion  of  HCl ;  and  also  of  mucus, 
when  there  is  a  complicating  catarrhal  process. 

For  reports  of  several  bad  cases  of  dilatation  cured  in  this 
way  see  Lecture  XLIV.  (Splanchnoptosis  Concluded,  etc.)  and 
also  especially  Lectures  XXIX.  and  XXX.  (Intragastric 
Methods  of  Treatment). 

Treatment  of  Atonic  Dilatation. — X^ext  let  us  consider  the 
cases  of  so-called  atonic  dilatation.  A  certain  proportion  of 
these  probably  owe  their  origin  to  a  former  hyperchlorhydria, 
which  through  lack  of  treatment  persisted  until  the  gastric 
glands  became  exhausted.  Under  this  head  of  atonic  dilata- 
tion it  will  be  convenient  to  class  all  cases  in  which  there  are 
no  indications  of  obstruction  of  the  pylorus,  either  mechanical 
or  spasmodic — no  tumor,  adhesions,  or  kinks  affecting  the 
stomach  or  the  duodenum — and  no  existing  excess  of  hydro- 
chloric secretion. 

In  the  treatment  of  this  class  the  diet  will  differ  mainly  (i) 
in  not  requiring  so  rigid  an  exclusion  of  the  irritants,  stimu- 
lants, and  sour  things;  (2)  in  not  permitting  a  liberal  use  of 
fats,  which  would  lessen  still  further  the  gastric  secretion  and 
aggravate  the  indigestion;  (3)  in  requiring  a  greater  restric- 
tion of  the  amount  of  fluid  ingested;  and  (4)  in  permitting  a 
much  freer  use  of  meats,  meat  juice,  fish,  oysters,  and  all  the 
more  digestible  forms  of  animal  foods,  since  the  stimulating 
property  of  this  kind  of  diet  is  no  objection,  but  rather  an 
advantage  in  the  atonic  conditions  now  under  consideration, 


TREATMENT  OF  DILATATION  OF  STOMACH  4II 

and  such  foods  contain  usually  a  large  amount  of  nourishment 
in  a  small  bulk.  They  are  besides  less  fermentable  than  most 
other  forms  of  nutriment.  But  care  must  be  taken  that  an 
undue  proportion  of  proteid  food  is  not  too  long  continued,  or 
nutrition  will  suffer;  and  it  will  often  be  necessary  to  assist  its 
digestion  by  administering  artificial  digestants  at  the  same 
time.  An  exclusive  milk  diet  usually  aggravates  these  cases, 
on  account  of  the  excessive  bulk  of  it  necessary,  and  for  this 
reason  the  full  Weir-Mitchell  rest  cure,  notwithstanding  its 
brilliant  success  in  so  many  other  ailments,  frequently  fails  in 
patients  who  have  true  atonic  dilatation  of  the  stomach. 

On  the  other  hand,  the  worst  cases  will  generally  respond 
satisfactorily  to  a  modified  rest  tveatincnt,  in  which  concen- 
trated foods,  both  proteid  and  carbohydrate,  take  the  place  of 
milk,  especially  when,  in  administering  the  massage  and  elec- 
tricity, an  unusual  amount  of  time  and  attention  is  devoted  to 
the  abdominal  region.  The  abdominal  massage,  both  in  gas- 
trectasis  and  gastroptosis,  needs  to  be  given  by  specially  trained 
manipulators,  with  the  particular  object  always  in  view  of 
crowding  upward  the  stomach  and  intestines  while  the  patient 
exhales,  and  effecting  contractions  of  the  visceral  muscles  as 
well  as  those  of  the  abdominal  wall  by  very  deep  and  thorough, 
but  never  rough  or  painful,  kneading  while  the  patient's  hips 
are  kept  higher  than  the  shoulders,  so  that  gravity  may  assist 
the  replacement. 

The  aggravated  cases  demanding  such  modified  rest  treat- 
ment are  nearly  always  in  women  and  are  in  large  part  attribut- 
able to  their  exceedingly  irrational  and  unhygienic  mode  of 
dress.  Hence,  when  these  patients  again  begin  to  go  about, 
it  should  be  made  plain  to  them  that  it  will  be  impossible  to , 
complete  the  cure  and  make  it  permanent,  unless  they  will 
wear  instead  of  the  usual  corset  either  a  straight-front  corset 
fitted  snugly  in  its  lower  part  only,  or  better  yet  a  reform  waist, 
which  causes  only  a  slight  or  no  constriction  of  the  upper 
abdominal  organs,  while  it  admits  of  having  the  skirts  all 
suspended  from  the  shoulders.     A  snug-fitting  elastic  belt  for 


412  THE    GASTRO-INTESTINAL    CLINIC 

the  lower  abdomen,  however,  often  proves  of  great  service  by 
limiting  the  sagging  tendency  of  the  viscera. 

Faradic  electricity,  in  the  atonic  cases  also,  can  generally  be 
given  effectively  through  the  stomach  from  front  to  back,  using 
as  full  doses  as  can  be  borne  with  the  largest-sized  electrodes, 
and  this  treatment  can  be  repeated  daily  with  advantage  for 
many  weeks  at  a  time.  More  speedy  results  can  be  obtained 
by  the  employment  of  the  current  from  a  coil  having  a  short 
coarse  wire  applied  directly  to  the  inner  walls  of  the  stomach 
by  means  of  the  intragastric  electrode ;  but  this  should  not,  as  a 
rule,  be  used  oftener  than  every  other  day,  nor  be  continued 
longer  than  four  weeks  at  a  time  without  an  intermission  of  a 
week  or  two.  During  its  use,  too,  the  stomach  contents  should 
be  analyzed  at  least  every  two  weeks  (better  every  week),  to 
note  the  effect  upon  the  secretion,  which  is  usually  stimulated 
by  such  a  current  at  first,  but  later  depressed. 

The  simpler  forms  of  hydrotherapy  applicable  in  atonic 
dilatation  include  cold  sponge  baths  and  salt  rubs  to  the  whole 
body,  followed  by  friction  with  a  coarse  towel,  -and  locally 
alternate  hot  and  cold  jet  douches,  or  alternate  affusions  of  hot 
and  cold  water  to  the  epigastric  region. 

The  gymnastic  exercises  need  not  differ  from  those  recom- 
mended for  the  hyperchlorhydric  cases.  Pulley  exercise  is 
often,  helpful,  even  for  patients  in  bed,  the  pulley  being  attached 
to  the  ceiling  or  foot  of  the  bed;  and  for  others  rowing  is 
particularly  useful.  The  series  of  exercises  described  in 
Lecture  XXIII.  are  also  very  useful. 

The  cases  of  atonic  dilatation  in  which  downward  displace- 
ment has  contributed  to  the  causation  need  the  same  treatment 
already  described,  except  that  in  these  the  abdominal  massage, 
electricity,  and  exercises  need  to  be  more  energetically  and 
persistently  carried  out,  and  in  addition  a  special  abdominal 
supporter  with  truss-like  springs  may  be  worn  constantly  with 
much  advantage,  except  when  the  patient  is  in  bed.  For 
patients  not  under  regular  mechanical  treatment  strapping  the 
abdomen  with  strips  of  adhesive  plaster,  as  described  in  Lee- 


TREATMENT    OF    DILATATION    OF    STOMACH  4I3 

ture  XL.,  affords  the  most  complete  palliation  possible  with 
also  a  decided  curative  tendency.  The  modified  rest  treatment 
is  often  indispensable  in  this  form  of  dilatation. 

Of  course,  in  all  cases  of  dilatation  secondary  to  tuberculosis, 
heart 'disease,  Bright's  disease,  or  other  systemic  affections,  no 
treatment  would  be  effective  which  did  not  include  especial  at- 
tention to  the  primary  malady.  General  debility,  anaemia, 
etc.,  whether  a  cause  or  consequence  of  the  dilatation,  would 
demand  their  appropriate  treatment,  which  should  include  all 
the  possible  hygienic  and  climatic  aids  as  well  as  suitable  tonic 
medication. 

In  all  the  forms  of  gastric  dilatation,  it  is  necessary  that  the 
stomach  should  be  completely  empty  at  least  once  in  the  twenty- 
four  hours.  AAdien  its  propulsive  powers  cannot  effect  this 
(especially  in  the  obstructive  forms)  lavage  must  be  resorted 
to.  The  washing  out  is  best  done  before  breakfast.  I  shall 
not  discuss  here  more  fully  the  technique  and  indications  for 
lavage,  since  it  has  been  fully  considered  in  Lecture  XXIX. 

In  addition  to  lavage  for  lessening  fermentation  antiseptic 
remedies  may  often  prove  of  some  service  if  the  effects  are 
carefully  watched.  These  are  fully  considered  in  Lecture 
XXXIV. 

The  Treatment  of  Gastric  Tetany  is  not  a  promising  one, 
about  three-fourths  of  the  reported  cases  having  proved  fatal. 
Xarcotic  drugs  fail  to  cure  by  themselves,  and  naturally  so 
since  the  disease  is  believed  to  be  due  to  poisons  formed  and 
retained  in  the  system.  Flushing  the  colon  thoroughly  with 
weak  alkaline  and  antiseptic  solutions  is  certainly  indicated, 
both  to  supply  the  system  with  needed  liquid  and  to  eliminate 
poisons.  Lavage  would  be  efficient  as  a  cleansing  agent,  but 
is  not  likely  to  be  practicable  in  a  fully  developed  attack.  The 
administration  of  nerve  sedatives  is  advisable  to  lessen  as  much 
as  possible  the  abnormal  reflex  excitability.  I  would  suggest 
as  a  safe  method  of  effecting  this,  either  the  hypodermic  in- 
jection of  atropine  in  full  doses — grn.  -^-^ — repeated  cautiously 
in  smaller  doses  once  in  two  or  three  hours  till  the  pupils  begin 


4H  THE    GASTRO-INTESTINAL    CLINIC 

to  dilate,  or,  what  might  answer  the  purpose  better,  the  em- 
ployment, after  irrigating  the  colon,  of  enemas  containing  in 
solution  dram  doses  of  sodium  bromide  with  half-dram  doses 
of  chloral,  guarded,  if  necessary  to  prevent  cardiac  depression, 
by  lo-grn.  doses  of  camphor. 


LECTURE  XL 

SPLANCHNOPTOSIS,  OR  DOWNWARD  DIS- 
PLACEMENTS OF  THE  ABDOMINAL  OR- 
GANS GENERALLY  (NEPHROPTOSIS, 
GASTROPTOSIS,  AND  ENTEROPTOSIS)— 
MOVABLE  KIDNEY 

These  are  associated  conditions  and  several  of  them  are 
likely  to  be  found  coexisting-.  That  is,  it  is  comparatively  rare 
to  have  one  or  both  of  the  kidneys  prolapsed  and  movable 
without  finding  the,  stomach  and  usually  also  the  colon,  as  well 
as  frequently  the  small  intestines,  displaced  downward  at  the 
same  time.  It  is  equally  uncommon  to  find  the  stomach  and 
colon  in  abnormal  positions  with  both  kidneys  in  their  places, 
though  this  may  occur.  The  same  causes,  a  loss  of  the 
abdominal  fat  and  weakening  of  the  muscles  aided  by  the 
mechanical  action  of  the  corsets  and  heavy  skirts  hung  from 
the  waist,  permit  the  customary  supports  of  all  these  organs 
at  times  to  give  way  and  their  ligaments  to  be  stretched  and 
elongated,  so  that  some  or  all  of  them  fall  or  gradually  sink 
to  lower  positions  in  the  abdominal  cavity.  The  liver  and 
spleen  also  are  liable  to  be  displaced  downward. 

It  was  Glenard  who,  in  1885,  first  described  these  displace- 
ments and  explained  their  clinical  significance,  though  other 
writers  had  previously  recognized  the  possibility  of  a  prolapse 
of  certain  of  the  viscera. 

It  matters  little  which  one  of  the  various  associated  ptoses  is 
first  considered  here,  but  since  the  surgeons  by  the  great 
prominence  which  they  have  given  to  movable  kidney 
(nephroptosis),  have  familiarized  the  profession  and  laity  both 
with  this  particular  displacement  much  more  than  with  the 


4lC  THE   GASTRO-INTESTINAL    CLINIC 

Others,  we  may  as  well  begin  with  it.  Probably  the  most 
frequent  one  of  the  group,  however,  is  gastroptosis,  and  we 
shall  consider  that  next. 

In  a  paper  entitled  Movable  Kidneys;  Their  Effect  upon 
the  Gastric  and  Intestinal  Functions,  which  I  read  before  the 
Medical  Society  of  Pennsylvania  in  1901,  I  discussed  this 
whole  subject  of  the  abdominal  ptoses  rather  fully  and  shall 
draw  largely  upon  the  contents  of  that  paper  in  this  considera- 
tion of  nephroptosis.  I  call  your  attention  particularly  to  the 
nomenclature  of  these  displacements.  Most  authors  have  fol- 
lowed Glenard  in  applying  the  term  enteroptosis  to  the  entire 
group  of  displacements  above  mentioned,  though  it  is  derived 
from  a  Greek  word  meaning  intestine  and  therefore  applies 
appropriately  to  a  descent  of  the  intestines  only,  and  not  to 
that  of  other  organs.  I  much  prefer  the  now  accepted  term 
splanchnoptosis,  which  is  derived  from  a  Greek  word  meaning 
viscus,  and,  therefore,  is  a  far  better  name  for  the  disease 
which  describes  a  falling  of  the  viscera  generally;  and  the 
affection  is  also  frequently  called  Glenard's  disease. 

Movable  Kidneys — Nephroptosis. — Glenard  described  a 
sagging  of  the  colon,  stomach,  and  one  or  both  kidneys,  the 
liver  being  also  sometimes  involved.  Such  a  dropping  of  the 
viscera  is  exceedingly  frequent  among  women,  and  Stockton 
estimates  that  over  half  of  them  are  thus  afflicted.  He  says  :^ 
"  The  fact  that  more  than  50  per  cent,  of  all  civilized  women 
in  all  classes  of  life  have  developed  the  condition  known  as 
enteroptosis,  which  means  that  the  stomach,  intestines,  very 
often  the  kidneys,  and  sometimes  the  liver,  are  dragged  down 
and  remain  permanently  out  of  their  position,  is  not  generally 
known.  Such,  however,  is  the  case ;  and  this  condition  more 
than  any  other  cause  is  responsible  for  the  constipation,  back- 
ache, debility,  biliousness,  early  loss  of  complexion,  headache, 
and  that  long  list  of  ailments  of  which  so  many  women  in  all 
civilized  countries  are  victims." 

'"A   Manual   of   Personal    Hygiene,"   Philadelphia,    1900;   Article   on 
Hygiene  of  Digestive  Apparatus,  by  Charles  G.  Stockton.  M.  D.,  p.  47. 


SPLANCHNOPTOSIS  417 

This  group  of  ptoses  directly  causes  a  large  proportion  of 
uterine  displacements,  and  in  such  cases  the  latter  are  often 
treated  in  vain  for  years  by  means  of  pessaries,  tampons,  etc., 
and  sometimes  even  by  operation,  while  the  unrecognized  ab- 
normality above  continues  its  disturbing  action,  the  right  kid- 
ney, stomach,  and  colon,  all  or  one  or  more  of  them  dropping 
down  into  the  pelvis  and  resting  directly  upon  the  bladder  and 
uterus  whenever  the  patient  is  upon  her  feet.  Scarcely  a 
month  passes  in  which  such  aggravated  cases  are  not  en- 
countered in  my  practice.^ 

Some  of  the  ablest  gynecologists  now  recognize  this  sequence 
of  events.  Gill  Wylie,  in  recently  discussing  melancholia, 
hysteria,  hypochondria,  etc.,  said :"  "  These  cases  are  fre- 
quently associated  with  relaxed  abdominal  organs,  when  there 
are  loose  kidneys,  ptosis  of  the  stomach  with  omentum  and 
intestines  crowding  down  in  the  pelvis  on  top  of  a  retroverted 
or  flexed  uterus,  and  the  patients  have  been  treated  indefinitely 
with  pessaries  for  falling  of  the  womb." 

Edebohls  has  referred  to  the  same  condition^  and,  going 
further,  insists  that  right  movable  kidney  is  often  the  cause  of 
chronic  appendicitis  by  pressure  upon  the  superior  mesenteric 
vein,  a  branch  of  which  carries  the  blood  from  the  appendix.^ 
There  is  no  denying  the  very  frequent  coexistence  of  movable 
right  kidney  and  chronic  thickening  of  the  appendix,  and  it 
has  been  noted  by  many  observers,  including  myself. 

There  is  much  plausibility  in  Edebohls'  view  that  movable 
kidney  by  its  pressure  may  produce  a  stasis  of  venous  blood  in 
the  cecum  and  appendix  and  thus  gradually  cause  chronic  in- 
flammation in  the  latter.     The  same  explanation  may  help  to 

■■  See  reports  of  cases  in  Lecture  XLIV.  further  on. 

'  Ansemia  as  Observed  in  a  Gynecological  Clinic,  etc.,  by  W.  Gill 
Wylie,  M.  D.,  Medical  Record,  May  20,  iSgg. 

^Relations  of  Movable  Kidney  and  Appendicitis  to  Each  Other,  etc.,  by 
George  M.  Edebohls,  M.  D.,  Medical  Record,  March  11,  1899. 

*  Chronic  Appendicitis  the  Chief  Symptom  and  Most  Important  Com- 
plication of  Movable  Right  Kidney,  by  Geo.  M.  Edebohls,  M.  D.,  The 
Post-Graduate,  February,  1899. 


41 8  TflE    GASTRO-INTESTINAL    CLINIC 

account  for  the  constipation  and  chronic  catarrh  of  other  por- 
tions of  the  colon  which  so  commonly  accompany  movable 
rig^ht  kidney. 

Nephroptosis,  or  prolapse  of  the  kidney,  is  conveniently 
divided  into  four  stages :  ( i )  that  in  which  a  part  only  of  the 
kidney  can  be  felt  below  the  ribs  upon  very  deep  inspiration; 
(2)  that  in  which  the  entire  kidney  descends  into  the  flank, 
between  the  last  rib  and  the  ileum,  and  usually  returns  with 
each  expiration;  (3)  that  in  which  the  kidney  may  be  found 
floating  anywhere  in  the  abdominal  cavity  between  the  last  rib 
and  the  pelvis;  and  (4)  that  in  which  the  kidney  is  fixed  by 
adhesions  in  a  wrong  position. 

Etiology. — It  is  of  practical  value  to  know  that  chief  among 
the  causes  of  movable  kidney  are  inherited  weak  constitutions, 
a  lack  of  development  of  the  abdominal  muscles  by  exercise, 
and  women's  very  unhygienic  dress,  including  corsets  ^  (espe- 
cially the  short  corsets  formerly  in  vogue,  since  these  constricted 
the  waist,  thus  helping  to  force  the  stomach  and  other  viscera 
down),  tight  waistbands,  and  heavy  skirts  exerting  downward 
traction  upon  the  abdominal  walls.  The  old  theory,  that  preg- 
nancy and  its  results  have  most  to  do  with  causing  loose  or 

1  Einhorn*  considers  the  corset  as  an  important  factor  in  the  causation 
of  the  abdominal  ptosis,  and  Kellogg,-}-  as  wqll  as  Dickinson,:}:  has  been 
ver^'  emphatic  in  condemning  this  injurious,  article  of  attire.  The  latter 
found  that  the  total  pressure  of  the  corset  varies  between  thirty  and 
eighty  pounds,  and  the  capacity  of  the  chest  for  expansion  is  restricted 
one-fifth  while  it  is  worn.  He  added:  "The  abdominal  wall  is  thinned 
and  weakened  by  the  pressure  of  the  stag's.  The  liver  suffers  more  direct 
pressure  and  is  more  frequently  displaced  than  any  other  organ.  The 
pelvic  floor  is  bulged  downward  bj"-  tight  lacing  one-third  of  an  inch." 
Kellogg,  in  150  cases  of  pelvic  disease,  reports  the  stomach  and  bowels 
displaced  in  138. 

*  Remarks  on  Enteroptosis,  by  Max  Einhorn,  M,  D.,  Medical  Record, 
April  13,  1901. 

f  The  Influence  of  Dress  in  Producing  the  Physical  Decadence  of 
American  Women,  bj^  J.  H.  Kellogg,  M.  D.,  Tratis.  Mich.  State  Med. 
Soc,  1891,  p.  41. 

:):  The  Corset,  Questions  of  Pressure  and  Displacement,  by  R.  L.  Dick- 
inson, M.  D.,  N.  V.  Med.  Jour.,  November  5,  1887. 


SPLANCHNOPTOSIS  4I9 

floating  kidneys,  has  been  disproved.  Roskam,  in  a  very  recent 
elaborate  article  on  the  subject  based  upon  a  study  of  147 
cases,  stated  that  all  but  4  of  these  were  in  women.  Of  these 
143  women,  83  were  young  girls  at  the  time  the  ptosis  began 
and  only  60  were  married.^ 

There  are  some  anatomic  peculiarities  in  the  conformation 
of  women  that  probably  render  the  kidneys  and  other  viscera 
more  liable  to  become  movable  in  them  than  in  men,  especially 
their  broader  pelves  with  relative  narrowness  of  their  chests 
and  upper  abdomens;  and  another  setiologic  fact  in  them  is 
thought  to  be  a  periodic  congestion  of  the  kidneys  at  the 
menstrual  periods.  The  kidneys  may  also  be  dislocated  by 
traumatism  such  as  falls,  blows,  or  strains. 

Albarran  cited  by  Roskam  reports  that  of  1176  cases,  87 
per  cent,  were  in  women ;  and  Kiister,  quoted  by  the  same,  had 
97  per  cent,  of  cases  among  women. 

It  is  nearly  always  the  right  kidney  which  is  involved. 
Edebohls  has  never  seen  the  left  kidney  alone  movable,  noi 
have  I,  though  Einhorn  "  and  other  observers  report  a  very 
small  proportion  of  such  cases.  Of  Roskam's  147  cases  there 
was  but  one  in  which  the  kidneys  were  both  movable,  all  the 
remaining  146  having  involved  the  right  side  only. 

Stiller  first  made  the  observation  that  in  congenitally  weak 
persons,  those  inheriting  a  tendency  to  neurasthenia,  tuber- 
culosis, anjemia,  etc.,  the  tenth  rib  is  usually  loose  or  floating — 
and  sometimes  also  the  ninth — not  attached  as  it  should  be  to 
the  sternum.  Such  patients  are  said  to  have  the  atonic  or 
enteroptotic  habit,  and  are  much  more  prone  to  displacements 
of  the  viscera  than  others.  They  should  have  an  extra  amount 
of  attention  given  to  their  hygiene  from  infancy,  especially  to 
their  muscular  development. 

Symptomatology. — The  symptoms  of  movable  kidney  may 
include  pain,  felt  nearly  always  in  front  over  the  region  of  the 

^  Le  rein  Mobile  et  son  traitement  {traitement  chirtirgical  excepte)  by 
Dr.  Roskam,  Annates  de  la  Socidte  Medicochiriirgicale  de  Lidge,  March, 
1901.  I 

■2  See  note  *,  p.  418. 


420  THE   GASTRO-INTESTINAL   CLINIC 

kidney  or  below  the  liver — usually  over  the  site  occupied  by  the 
displaced  organ  at  the  time.  There  is  generally  more  pain  in 
\he  first  and  second  stages  of  the  affection  than  in  the  third, 
that  of  true  floating  kidney;  but  in  a  large  proportion  of  all 
the  cases  there  is  no  local  pain,  except  occasionally. 

Disturbances  of  the  digestion  constitute  the  most  frequent 
symptoms.  These  include  predominantly  those  of  hyperchlor- 
hydria — pain,  or  burning,  coming  on  at  times  shortly  after  eat- 
ing, but  more  commonly  toward  the  height  of  the  digestive 
period,  one  to  three  hours  after  eating.  I  had  flattered  myself 
that  I  was  the  first  to  observe,  in  the  year  1899,  ^^^^  movable 
kidney  tended  in  many  cases  to  stimulate  reflexly  the  gastric 
glands  to  excessive  secretion,  the  dyspepsia  in  such  cases  be- 
ing generally,  at  least  at  first,  of  the  hyperchlorhydric  form. 
I  find  now,  however,  that  our  French  confreres  seem  to  have 
made  the  same  observation  before. 

Rosewater,  of  Cleveland,  O.,  in  a  paper  ^  published  in  the 
year  1900,  referred  to  gastric  hyperacidity  as,  one  of  the 
neuroses  that  may  result  from  enteroptosis.  Of  the  eight  cases 
of  the  latter  reported  by  him  four  had  movable  kidney,  and  in 
two  of  these  both  the  right  and  left  kidneys  were  thus  affected. 
He  also  mentioned  dilatation  of  the  stomach  as  a  disease  that 
"  may  result  through  traction  or  by  pressure  of  the  right  kid- 
ney upon  the  pyloric  end." 

As  usual  when  the  HCl  of  the  gastric  juice  is  in  large  excess, 
there  is  much  flatulency,  sour  eructations,  often  waterbrash, 
and  sometimes  crises  of  severe  pain  in  the  stomach,  followed  by 
the  vomiting  of  a  thin  liquid  which  is  so  acid  as  to  set  the  teeth 
on  edge,  but  without  the  sour  odor  of  fermenting  ingesta. 
There  is  very  generally  constipation  also  as  a  result  of  the 
HCl  excess,  even  if  not  from  pressure  of  the  displaced  kidney 
upon  the  duodenum  or  upon  one  of  the  large  veins,  as  men- 
tioned by  Edebohls.  There  are  also  frequently  insomnia, 
mental  depression,  and  when  the  mobility  of  the  kidney  con- 

1  Enteroptosis  Relative  to  Disorders  of  the  Digestive  Tract  and  Circu- 
lation, by  N.  Rosewater,  M.  D.,  Cleveland  Jour,  of  Med.,  June,  1900. 


SPLANCHNOPTOSIS  421 

tinues  long,  especially  when  it  is  a  part  of  a  general  sagging 
of  the  abdominal  organs,  neurasthenia  is  almost  sure  to  de- 
velop, even  if  not  present  before. 

The  kidney  may  be  very  sensitive  on  palpation,  especially  in 
the  first  two  stages  of  nephroptosis,  but,  according  to  my 
experience,  one  may  cjuite  as  frequently  meet  with  kidneys 
which  are  movable  and  in  either  the  first  or  second  position  of 
descent,  without  being  painful  on  moderate  pressure. 

In  time  the  stomach  may  become  dilated  as  a  result  of  the 
frecjuent  and  prolonged  pyloric  spasm  from  hyperacidity,  or 
from  pressure  by  the  kidney  as  stated  by  Rosewater,  and  then 
the  familiar  symptoms  of  dilatation  develop,  though  rarely 
in  the  same  degree  that  they  do  in  cases  of  permanent  ob- 
struction of  the  pylorus  as  from  tumor,  or  the  scar  of  an 
ulcer. 

Diagnosis  of  Movable  Kidneys. — Displaced  or  movable  kid- 
ney can  easily  be  differentiated  from  any  other  abnormal  con- 
dition, and  in  most  cases  by  palpation  alone.  The  numerous 
possible  symptoms  are  never  by  themselves  diagnostic,  and 
indeed  are  often  all  absent.  The  kidney  must  be  palpated  and 
recognized  by  its  peculiar  shape  and  smooth  feel  in  its  wrong 
position,  and,  when  freely  movable,  can  be  felt  to  slip  through 
between  the  fingers  with  one  hand  placed  over  the  loin  behind 
and  the  other  in  front.  With  the  patient  lying  supine,  her 
bands  loosened  and  knees  flexed  (or  as  Noble  ^  prefers,  stand- 
ing and  the  upper  part  of  the  body  bent  forward  almost  at 
right  angles  while  her  hands  rest  upon  a  table  or  desk),  the 
physician  should  press  the  finger  tips  of  one  hand  deeply  into 
the  loin  just  below  the  normal  position  of  the  kidney,  and  press 
the  fingers  of  the  other  hand  over  the  corresponding  region 
in  front.  Then,  with  the  two  hands  thus  brought  near  to- 
gether, the  patient  is  caused  to  inhale  and  exhale  very  deeply, 
and  if  the  kidney  is  movable,  it  will  be  plainly  felt  to  slip  out 
on  inspiration  and  return  through  the  fingers  to  its  normal  site 

^  Nephrorrhaphy,  by  Charles  P.  Noble,  M.  D.  Presented  to  the  Section 
on  Obstetrics  and  Diseases  of  Women,  Am.  Med.  Assoc,  June  5-8,  1900. 


422 


THE    GASTRO-INTESTINAL    CLINIC 


on  forcible  expiration  with  the  mouth  partly  open/  (See 
accompanying  illustration.)  When  this  procedure  fails  to 
detect  it,  gentle  but  deep  palpation  should  be  practiced  all 
over  the  abdomen,  while  the  recumbent  patient  relaxes  as  much 
as  possible  and  continues  deep  breathing.  In  this  manner  a 
floating  kidney  which  no  longer  returns  to  its  place,  or  one 


Fig.  54. — Palpation  of  movable  kidney.     Reproduced  from  an  article  by- 
Henry  Morris,  in  Lancet,  November  30,  1901. 

which  is  held  by  adhesions  or  otherwise  in  a  false  position,  can 
generally  be  discovered,  except  when  it  has  become  fixed  be- 
hind some  other  organ. 

By  percussing  over  the  renal  region  behind  and  evoking 
tympany  there  where  there  should  be  dullness,  confirmation 
may  be  obtained  of  the  absence  of  the  kidney  from  its  place. 

Prognosis.— Clinicians  who  have  had  most  experience  in 
treating  these  cases  agree  that  a  cure  may  now  be  obtained  in 
a  certain  proportion  of  them,  even  without  surgical  interven- 
tion, when  the  patients  can  afford  to  take  the  necessary  care  of 
themselves  and  be  under  skilled  medical  supervision ;  and  when 
a  complete  cure  cannot  be  obtained,  the  patients  can  nearly 
always  be  relieved  of  the  painful  and  harmful  symptoms,  and 

■*  The  above-described  method  of  examining  for  movable  kidney  with 
the  patient  recumbent  was  demonstrated  to  the  author  by  Oser  of  Vienna, 
in  1885,  and  again  by  Ewald  and  Kuttner  at  the  former's  clinic  in  Berlin 
in  1S95.  Even  a  very  slight  mobility  can  be  detected  in  this  way  when 
one  has  had  sufficient  practice  in  palpation. 


SPLANCHNOPTOSIS  423 

that,  too,  very  speedily.  My  own  most  recent  experience  has 
encourag-ed  me  to  hope  for  a  definite  cure  in  the  mild  or  less 
aggravated  cases  by  mechanical,  hygienic,  and  medicinal 
measures  in  patients  possessing  the  leisure  and  means  to  com- 
mand appropriate  treatment.  Even  nephropexy  by  no  means 
always  cures;  after  the  operation  a  relapse  of  the  trouble 
often  occurs. 

Treatment  of  Movable  Kidneys. — This  should  begin  by 
confinement  to  bed  under  some  form  or  modification  of  the 
rest-cure  method  in  all  cases  in  v/hich  the  movable  kidney  is 
either  spontaneously  painful  or  tender  on  palpation.  If,  even 
with  the  patient  recumbent,  the  kidney  descends  below  the  ribs 
during  moderate  inspiration,  retentive  apparatus  must  be  put 
on  and  worn  in  bed. 

Strapping  the  Abdomen  for  Displacements. — At  one  time 
I  employed  in  most  of  my  cases  of  movable  kidney  an  oblong 
pad,  which  was  attached  to  an  abdominal  belt  in  such  a  way 
as  to  afford  support  directly  to  the  kidney.  This  could  usually 
be  made  to  effect  the  object  and  in  most  of  the  cases  prevent 
any  demonstrable  prolapse,  but  was  troublesome  to  adjust  by 
the  patient,  often  uncomfortable  and  what  was  worse,  some- 
times, especially  when  not  skillfully  adjusted  by  the  patient  or 
her  maid  before  dressing  in  the  morning,  the  pressure  of  the 
pad  seemed  to  interfere  with  the  return  flow  of  blood  from  the 
veins  of  the  lower  abdomen,  and,  in  one  case  at  least,  I  had 
reason  to  believe  that  an  aggravation  of  a  previously  existing 
chronic  catarrhal  appendicitis  resulted  from  this  cause. 
Therefore  I  have  been  depending  of  late  in  most  cases  upon 
either  a  well-fitting  elastic  abdominal  belt,  or  upon  what  has 
proved  a  much  more  satisfactory  method  of  retaining  movable 
kidneys  as  well  as  other  displaced  abdominal  organs  in  their 
normal  positions.  This  is  by  means  of  strapping  the  abdomen 
with  adhesive  plaster  as  first  recommended  and  practiced  by 
Dr.  A.  Rose  of  New  York,  except  that  in  most  cases  I  apply 
much  less  of  the  plaster  than  Rose  does,  not  finding  it  necessary 


424  THE    GASTRO-INTESTINAL    CLINIC 

to  cover  in  this  way  a  large  part  of  the  lower  abdomen.  As  car- 
ried out  in  my  practice,  the  technique  is  as  follows :  While  the 
patient  lies  on  her  back  with  the  hips  well  raised  to  assist  the 
replacement  by  gravity,  she  is  directed  to  exhale  several  times 
very  forcibly  and  hold  the  breath  out  afterward  as  long  as 
possible.  Meanwhile  the  physician  makes  upward  pressure 
wath  both  hands  placed  over  the  lower  abdomen.  In  this  way 
it  is  usually  easy  to  replace  the  organ  completely.  After  this 
has  been  effected  the  patient  should  again  hold  the  breath 
momentarily  while  the  physician  applies  the  first  strip  of 
plaster  on  the  right  side.  In  applying  this  one  end  of  a  roll 
of  the  best  Z.  O.  adhesive  plaster,  25/^  inches  wide,  is  attached 
firmly  to  the  skin  as  near  to  the  groin  on  the  left  side  of  the 
body  as  the  pubic  hairs  will  permit,  and  then  brought 
diagonally  upward  and  to^  the  right,  passing  usually  a  little 
below  the  umbilicus  and  on  around  over  the  region  below  the 
liver  anteriorly  and  the  right  side  of  the  thorax,  to  a  point 
near  the  spine  in  the  mid-dorsal  region  or  sometimes  a  little 
higher,  the  exact  course  and  upper  limit  of  the  plaster  depend- 
ing somewhat  upon  the  size  and  shape  of  the  thorax.  After 
attaching  the  lower  end  of  the  plaster  to  several  inches  of  the 
surface  it  will  generally  adhere  sufficiently  to  permit  of 
moderate  upward  traction  while  the  remainder  of  the  strip  is 
applied,  or  if  it  does  not  stick  well  enough  without,  an  assistant 
may  need  to  hold  one  hand  firmly  over  the  part  first  applied 
while  such  traction  is  being  made.  The  first  strips  of  plaster 
need  to  be  drawn  upward  with  just  sufficient  force  to  hold  the 
lower  abdomen  nearly,  but  not  quite,  up  to  its  normal  place,  else 
the  patient  will  be  rendered  uncomfortable  and  very  likely 
refuse  to  let  them  remain ;  but  after  wearing  them  a  week  or 
two  she  will  tolerate  them  better,  and  full  replacement  can  then 
usually  be  effected  and  maintained  by  the  plaster  strips  without 
more  than  a  slight  inconvenience.  I  speak  of  this  in  connec- 
tion with  the  application  of  the  first  strip,  since  the  others  must 
bea])[)lie(l  similarlv  in  order  to  have  the  abdomen  symmetrically 
supported.     The  second  strip  is  applied  to  the  opposite  side  in 


SPLANCHNOPTOSIS  425 

an  exactly  reverse  way  from  the  first.  In  the  cases  of  thin 
women  without  much  accompanying  displacement  of  the 
stomach  or  intestines,  I  often  find  one  pair  of  such  broad  strips 
of  adhesive  plaster  all-sufficient  to  maintain  adequate  support, 
but  in  others  additional  ones  are  required.  In  such  cases  the 
first  pair  of  strips  are  placed  nearer  to  the  umbilicus  and  the 
second  adjoining  the  first  on  the  outer  side.  When,  on  account 
of  warm  weather  or  other  cause,  the  strips  show  a  tendency 
to  slip  upward,  not  holding  well,  I  apply  other  strips  trans- 
versely over  them  so  as  to  secure  them  more  firmly.  The  same 
precaution  is  sometimes  necessary  also  on  the  back. 

The  foregoing  is  the  technique  which  I  have  worked  out  for 
myself,  not  having  had  the  opportunity  of  seeing  Dr.  Rose 
apply  the  plaster.  Doubtless  my  technique  can  be  improved  upon, 
but  it  has  produced  satisfactory  results  in  numerous  cases. 
Occasionally  patients  having  very  sensitive  skins  complain  of 
annoyance  from  the  itching  sensation  produced  by  the  plaster, 
and  in  some  a  temporary  papular  eczema  is  likely  to  result 
when  it  is  worn  beyond  three  or  four  weeks  at  a  time.  In 
such  cases  I  have  an  elastic  belt  fitted,  to  be  worn  as  an 
abdominal  supporter  until  the  skin  will  again  tolerate  the  plas- 
ter. The  support  furnished  by  the  latter  is  so  much  more 
complete  and  satisfactory  than  that  obtained  from  any  possible 
form  of  belt  that  most  patients  are  very  willing  to  put  up  with 
the  comparatively  slight  inconvenience  which  it  involves. 
After  four  to  six  weeks  the  plaster  strips  need  to  be  renewed, 
in  any  case,  since  they  have  generally  become  loose  in  that  time, 
and  it  is  well  to  have  then  some  sort  of  a  belt  worn  as  a  pro- 
visional support  for  a  day  or  two  before  new  strips  are  applied, 
so  as  to  allow  the  skin  to  be  thoroughly  cleansed  and  dried 
and,  I  might  add,  rested,  since  any  skin  would  be  likely  to 
become  irritated  after  a  too  long  continuous  application  of 
the  plaster. 

OfJicr  Rciuedial  Measures.     Patients  who  are  neurasthenic 

enough  to  require  the  full  rest  cure,  as  well  as  those  who  need 

,to  be  recumbent  for  a  while  at  first  because  of  the  very  sensitive 


4^6  THE    GASTRO-INTESTINAL    CLINIC 

condition  of  the  kidneys,  will  not,  as  a  rule,  have  to  be  kept 
strapped  while  in  bed.  In  most  such  cases  the  movable  kid- 
ney  or  kidneys  will  remain  in  position  so  long  as  the  patient  is 
recumbent,  or,  if  not,  a  simple  elastic  belt,  'snugly  buckled,  will 
furnish  support  enough  under  such  circumstances.  It  is  im- 
portant also  during  such  a  rest  treatment  to  have  the  patient's 
abdomen  unhampered  so  that  really  curative  measures,  such  as 
massage  and  electricity,  can  be  regularly  applied.  For  the  same 
reason,  in  the  lighter  cases  of  displacement,  when  these  mechan- 
ical treatments  can  be  had  every  day  or  every  other  day  in  the 
hope  of  permanently  overcoming  the  abnormal  condition,  it 
will  be  advisable  to  put  up  with  the  less  perfect  support 
furnished  by  a  simple  elastic  belt  rather  than  to  apply  plaster 
strips,  which  somewhat  interfere  with  an  effective  strengthen- 
ing of  the  abdominal  muscles  by  the  means  mentioned.  But, 
for  the  large  proportion  of  walking  patients,  who  cannot  or  w^ill 
not  undergo  a  systematic  treatment  which  must  extend  over 
months,  the  strapping  with  plaster  affords  by  all  odds  the  most 
efficient  form  of  support  I  have  ever  tried.  Indeed,  since 
having  learned  how  to  use  it  properly  I  have  not  been  obliged 
to  have  the  operation  of  nephropexy  performed  in  a  single 
case.  The  latter,  however,  when  it  shall  have  been  so  per- 
fected as  to  retain  the  kidney  in  place  during  the  remainder 
of  the  patient's  life  with  a  reasonable  degree  of  certainty,  will 
be  indicated  in  many  of  the  more  aggravated  cases  of  nephrop- 
tosis which  are  not  associated  with  displacements  of  others 
of  the  abdominal  organs,  or  after  such  other  associated  dis- 
placements have  been  remedied  without  overcoming  the  mo- 
bility of  the  kidney. 

Even  in  these  exceptional  cases  of  severe  nephroptosis  which 
persist  when  the  stomach  and  intestines  after  a  long  siege  with 
strengthening  measures  have  been  restored  nearly  to  their 
normal  positions,  there  is  always  some  hope  of  effecting  an 
ultimate  cure  by  fattening  the  patient  when  possible,  since  this 
restores  the  normal  cushion  of  flesh  which  constitutes  a  large 
part  of  Nature's  dependence  for  the  support  of  the  kidneys. 


SPLANCHNOPTOSIS  427 

The  rest  cure  is  a  decided  help  in  this  direction  when  otherwise 
indicated,  and  is  therefore  to  be  recommended  in  such  cases 
when  practicable. 

The  task  of  the  physician  will  be,  in  brief,  to  fatten  and  build 
up  his  patient  in  every  way,  and  above  all  to  strengthen  her 
abdominal  muscles  by  exercises  specially  designed  for  this  pur- 
pose, aided,  when  necessary,  by  short  jet  douches  or  affusions 
of  cold  water,  as  well  as  by  electricity  and  massage  very 
cautiously  given,  avoiding  irritation  of  the  tender  kidneys. 

The  diet  should  meanwhile  be  as  nutritious  as  the  patient 
can  take  and  digest,  regard  being  had,  when  practicable,  to  the 
results  of  an  analysis  of  the  stomach  contents  after  a  test  meal. 
These  patients  are  almost  invariably  thin  in  flesh,  and,  there- 
fore, fattening  food  is  particularly  suitable,  with  plenty  of  rest 
in  a  recumbent  position,  especially  after  meals,  and  when  this 
rest  can  be  taken  in  the  open  air,  it  is  so  much  the  better. 

Drugs  are  little  needed  for  the  displacement  or  mobility 
itself,  but  tonics  may  sometimes  be  used  temporarily  to  fortify 
the  constitution,  when  judiciously  prescribed,  and  the  usual 
remedies  for  an  accompanying  hyperchlorhydria  are  often  re- 
quired at  first.  In  my  experience,  the  cases  of  movable  kidney 
which  are  not  at  rest  mentally,  physically,  and  sexually,  and 
which  do  not  yield  promptly  to  treatment,  will  frequently 
develop  a  stubborn  form  of  hyperchlorhydria  with  its  re- 
sulting burning  pain  in  the  stomach.  Sometimes  this  cannot 
be  controlled  even  by  drugs  and  diet  together  with  the  aid  of 
rest,  and  then,  in  the  absence  of  peptic  ulcer,  may  yield  to  a 
course  of  high-tension  faradism  applied  intragastrically.  These 
methods  will  usually  reduce  the  HCl  excess  temporarily,  but  if 
the  kidney  be  not  retained  in  place  by  some  means,  the  derange- 
ment of  secretion  will  soon  recur.  Cases  not  amenable  to 
milder  measures  should  have  the  operation  to  anchor  the  kid- 
ney in  place — nephropexy.  This  should  always  be  done  when 
a  severe  hyperchlorhydria  due  to  the  displacement  cannot  be 
relieved  otherwise,  and  for  all  patients  who  cannot  obtain  suit- 
able medical  and  mechanical  treatment. 


428  THE   GASTRO-IXTESTIXAL    CLINIC 

Benninghoff  has  recommended  a  modified  Trendelenberg 
position  secured  by  raising  the  foot  of  the  bed  in  the  more 
stubborn  ptoses  of  the  viscera. 

Great  Importance  of  Correcting  Displacements No  other 

remedial  measure  ever  employed  by  me  in  any  disease  has 
produced  even  one-half  the  good  that  has  followed  the  replace- 
ment and  retention  of  prolapsed  stomachs  and  other  abdominal 
viscera  by  the  methods  herein  described. 

A  physician's  wife  in  Los  Angeles  had  suffered  some  years 
with  aggravated  neurasthenia,  mental  depression,  and  occa- 
sional attacks  of  acute  pain  in  the  right  side.  Cured  at  once  of 
the  worst  symptoms  by  correcting  a  previously  unrecognized 
nephroptosis,  and  good  health  restored  after  a  course  of  rest 
treatment.  The  kidney  had  become  swollen  and  very  tender 
to  the  touch. 

A  number  of  cases  of  previously  intractable  asthma  have 
yielded  after  mechanically  supporting  displaced  viscera.     One 
great  sufferer  from  asthma  who  had  gone  the  rounds  of  the 
regular  profession,  besides  having  tried  osteopathy.  Christian. 
Science,  etc.,  was  found  to  have  a  particularly  bad  gastroptosis j 
with  the  stomach  held  down  by  adhesions.    I  advised  operation, 
but  the  surgeons  to  whom  she  first  applied  could  not  confirm 
my  diagnosis,  not  having  either  inflated  the  stomach  or  had  an 
x-ray  picture  made.     Some  time  later   other   surgeons   con- 
firmed the  diagnosis  by  both  inflation  and  opening  the  ab-' 
domen,  but  the  patient  bore  the  ether  so  badly  that  the  opera- 
tion could  not  be  completed  after  some  small  ovarian  C3'sts  and 
a  catarrhal  appendix  had  been  first  removed.     Her  stomach 
is  still  partly  in  the  pelvis,  and  she  still  suffers  much  from  the^ 
asthma. 

In  another  case  of  severe  asthma  in  a  stout  fleshy  young' 
man  seen  by  me  at  Dr.  Corey's  Sanatorium  in  Alhambra,  Cal., 
a  gastroptosis  was  overcome  by  strapping,  as  already  de- 
scribed, with  instant  relief  of  the  dyspnea,  and  there  has  been 
no  trouble  from  it  since,  so  long  as  his  abdomen  has  been 
kept  supported. 


LECTURE  XLI 

SPLANCHNOPTOSIS,  CONTINUED.  DIS- 
PLACEMENTS AND  DISTORTIONS  OF 
THE     STOMACH 

The  stomach  can  be  displaced  in  various  ways — upward, 
downward,  (gastroptosis),  and  in  either  direction  laterally. 
Occasionally  in  women  it  is  displaced  upward  in  consequence 
of  the  constriction  of  the  corset,  when  this  article  of  attire  is 
begun  to  be  worn  before  the  stomach  has  dropped  or  been 
enlarged  downward ,  and  the  level  of  the  constriction  is  well 
below  the  viscus.  It  may  also  result  from  contraction  of  the 
left  lung  and  as  a  sequel  of  left-side  pleurisy  or  of  diaphrag- 
matic pleurisy.  This  accident  is  much  less  likely  to  produce 
symptoms  than  a  ptosis  or  sagging  of  the  organ,  and  is  doubt- 
less often  overlooked ;  but  palpitation  of  the  heart  might  be 
expected  to  result  from  the  distention  of  such  a  stomach  with 
gas.  Such  a  malposition  would  not  be  so  likely  as  the  opposite 
kind  of  displacement  to  cause  a  kinking  of  the  duodenum,  and 
even  if  it  could,  the  resulting  obstruction  would  produce  a 
dilatation  of  the  stomach  which  would  again  carry  the  greater 
curvature  downward  to  a  level  at  or  below  the  normal. 

Lateral  displacements  are  probably  very  rare  and  are  likely 
never  to  be  seen  except  as  a  result  of  the  pressure  of  a  tumor, 
or  enlargement  of  one  of  the  adjacent  organs  from  any  cause. 

The  same  methods  already  described,  and  those  explained 
below,  will  enable  you  to  diagnosticate  with  but  little,  if  any, 
difficulty  either  an  upward  or  a  lateral  displacement  of  the 
stomach.  The  only  possible  remedies  for  any  of  them  are  to 
be  found  in  a  removal  of  the  cause,  whether  it  be  a  faulty  mode 
of  dress  or  a  morbid  growth. 


430  THE  GASTRO-INTESTINAL   CLINIC 

Since  downward  displacement  of  the  stomach  is  exceedingly- 
common  and  the  other  malpositions  very  rare  in  comparison,  I 
will  proceed  at  once  to  the  consideration  of  this  highly  im- 
portant condition. 

Gastroptosis. — This  is  by  far  the  most  common  of  all  gastric 
derangements  as  well  as  one  of  the  most  frequent  causes  of  im- 
paired health  in  women  especially,  and  at  the  same  time  one  of 
the  most  readily  relieved,  if  not  often  radically  cured.  The 
greater  curvature  is  usually  considered  to  be  in  health  well 
above  the  umbilicus — one-third  to  two  inches  or  more,  ac- 
cording to  recent  x-ray  experiments.  Numerous  observers 
seem  to  have  demonstrated  also  by  the  same  means  that  the 
stomach  should  occupy  a  more  vertical  position  than  formerly 
thought,  the  pylorus  being,  in  healthy  children  at  least,  a  little 
lower  than  any  other  part — i.e.  till  unhygienic  dress,  overeat- 
ing, etc.,  have  formed  a  dependent  pouch  at  the  greater  curva- 
ture. Whenever  the  latter  is  found  at  or  below  the  umbilicus, 
there  must  be  either  a  gastroptosis  or  gastrectasis  (dilatation) 
unless  we  are  able  to  demonstrate  enlargement  without  weak- 
ening of  the  walls,  which  would  signify  merely  hypertrophy 
of  the  stomach  (megastria).  If  at  the  same  time  the  upper 
part  of  the  stomach,  as  shown  by  the  position  of  the  lesser 
curvature  and  the  fundus,  is  much  too  low,  there  exists  evi- 
dently gastroptosis  and  not  dilatation. 

jS^tiology. — The  causes  of  gastroptosis  are  in  the  main  the 
same  as  those  of  nephroptosis,  and  little  space  need  be  oc- 
cupied with  a  repetition  of  them.  All  authors  with  but  few 
exceptions  agree  that  prominent  among  them  are  the  faulty 
dress  of  women  who  almost  monopolize  the  disease,  and  the 
wasting  diseases  that  cause  a  loss  of  fat  and  muscle  tone. 
Nevertheless,  the  disease  is  not  very  infrequent  in  men, 
especially  among  heavy  eaters  and  those  accustomed  to  sup- 
port their  trowsers  by  tight  waistbands  or  belts.  Perhaps 
you  should  be  informed  here  also  concerning  the  plausible 
theory  of  Glenard,  though  it  is  not  now  generally  accepted. 
He  believed  that  the  first  step  in  the  chain  of  causes  that  led 


SPLANCHNOPTOSIS 


431 


finally  to  a  dropping  of  all  or  several  of  the  abdominal  organs, 
was  the  fall  of  the  right  end  of  the  colon  at  the  hepatic  flexure. 
Downward  with  this,  according  to  his  theory,  then  goes  the 
entire  ascending,  and  the  right  half  of  the  transverse,  colon  so 
that  the  latter  follows  a  nearly  straight  line  diagonally  from 
the  cecum  to  the  splenic  flexure  at  the  left,  where  there  results 


Fig.  55. — Splanchnoptosis  with  marked  gastroptosis,  coloptosis,  etc.  i, 
liver.  2,  stomach.  3,  transverse  colon.  (From  Prof.  Dr.  C.  A.  Ewald's 
"  Krankheiten  des  Darms  und  des  Bauchfells.") 


a  sharp  kinking  with  obstruction  of  the  lumen.  In  consequence 
of  this  obstruction  there  follows  a  dilatation  of  all  that  part  of 
the  colon  to  the  right  of  the  kinking  together  with  stagnation 
of  its  contents.  The  prolapsed  transverse  colon  was  then  sup- 
posed to  pull  down,  one  after  another,  the  other  viscera  whose 
ligamentous  supports  have  become  weakened.     Ewald,  Kutt- 


432  THE    GASTRO-INTESTINAL    CLINIC 

ner,  and  others  have  proved  that  this  theory  was  not  in  accord 
with  all  the  facts,  and  though  the  falling  of  one  organ  does  often 
prbduce  obstruction  by  kinking,  and  though  its  weight,  in- 
creased by  an  abnormal  stagnation  of  its  contents,  helps  to 
drag  down  others,  the  precise  order  of  occurrences  described 
by  Glenard  cannot  be  shown  to  exist  as  a  rule.  It  is  probable 
that  in  some  cases  of  aggravated  constipation  the  overloaded 
colon  does  first  sag  and  then  pull  down  the  stomach  with  other 
organs,  and  quite  certain  also  that  in  other  cases  a  constantly 
overloaded  stomach  sometimes  finall}^  gives  way  (especially  in 
women  who  lace  tightly  and  let  their  skirts  drag  upon  their 
abdominal  muscles  instead  of  suspending  them  from  the 
shoulders),  and  then  crowds  down  before  it  the  transverse 
colon;  and  very  likely  there  may  result  further  a  prolapse  of 
one  or  both  kidneys  in  consequence  of  the  changes  in  the  posi- 
tion of  such  large  viscera. 

Symptomatology. — The  most  constant  symptom  of  gastrop- 
tosis  is  constipation,  though  even  this  is  sometimes  absent,  and 
along  with  this  there  is  usually  associated  a  sluggish  digestion, 
with  flatulence,  a  lowered  nerve  tone  with  often  insomnia  and 
pronounced  neurasthenia.  In  severe  cases  anaemia  soon 
develops  and  ultimately  profound  debility.  When,  as  usual, 
there  is  a  complicating  muscular  insufficiency  of  the  stomach 
or  dilatation,  you  may  observe  the  inevitable  symptoms  of  such 
complication,  viz.,  a  splashing  sound  over  the  stomach,  retention 
of  food,  greatly  increased  flatulence  and  diminution  of  urine 
with,  in  bad  cases,  vomiting  of  fermenting  stomach  contents 
from  time  to  time.  The  more  common  dyspeptic  symptoms 
which  you  will  encounter  in  moderate  cases  of  gastroptosis  are 
sensations  of  dragging,  weight  or  pressure  in  the  epigastrium, 
and  any  of  the  uncomfortable  feelings  associated  with  dys- 
pepsia except  that  there  is  rarely  burning  or  acute  pain.  The 
latter  generally  depends  upon  an  excessive  secretion  of  HCl 
when  not  a  result  of  ulcer  or  cancer,  though  gastralgic  pains  do 
occur  without  any  ascertainable  cause  except  some  fault  in  the 
nervous  system.     When  the  displacement  is  not  marked  and 


SPLANCHNOPTOSIS  433 

the  gastric  muscle  still  strong",  there  may  be  no  symptoms  at 
all. 

Diagnosis. — Indispensable  to  the  diagnosis  of  a  displacement 
is  a  correct  idea  of  the  normal  position,  size,  and  form  of  the 
organ  involved.  As  to  the  stomach,  these  are  described  and  il- 
lustrated on  pages  31  and  32.  The  stomach  has  been  er- 
roneously described  and  pictured  as  occupying  a  vertical  posi- 
tion because  a  swinging  of  the  pylorus  downward  and  to  the 
left  is  such  a  very  common  displacement  that  some  authors  have 
considered  it  normal.  Downward  displacement  of  the  stomach 
is  often  mistaken  for  dilatation,  but  cannot  easily  be  con- 
founded with  any  other  condition.  To  make  the  differential 
diagnosis  between  these  two  diseases  you  have  merely  to  deter- 
mine first  the  position  of  the  greater  curvature,  which  any  tyro 
should  be  able  to  do  after  a  few  minutes'  instruction,  by  simply 
practicing  percussion  and  clapotage,  as  described  in  Lecture 
VI.,  and  then  by  inflating  the  viscus  with  carbonic  dioxide  and 
percussing  again  to  find  the  position  of  the  lesser  curvature  and 
of  the  fundus.  When  both  curvatures  are  too  low,  you  have, 
of  course,  gastroptosis.  After  a  full  inflation  so  that  the 
stomach  shall  be  markedly  tympanitic  everywhere,  you.  could 
not  well  be  left  in  doubt  as  to  the  position  of  any  part  of  the 
organ.  Even  when  the  pylorus  and  lesser  curvature  are  up 
under  the  left  lobe  of  the  liver,  deep  percussion  will  bring  out 
the  tympanitic  sound.  Should  there  remain  a  doubt  as  to  the 
diagnosis,  the  introduction  of  Turck's  gyromele  or  the  electric 
lamp  (gastrodiaphane)  into  the  stomach  would  help  to  solve 
it.  In  thin  patients,  too,  a  radiograph  of  the  abdomen  should 
settle  the  matter. 

Prognosis. — Gastroptosis  can  generally  be  greatly  ame- 
liorated by  medical  and  mechanical  treatment  and  a  symptom- 
atic cure  thus  effected,  though  it  cannot  be  radically  cured  in 
all  cases.  Restoring  the  tone  of  the  abdominal  muscles  by 
massage  and  electricity,  aided  when  necessary  by  hydriatic 
measures,  will  often  go  far  toward  overcoming  the  milder 
cases  and  can  markedly  lessen  the  displacement  in  the  severer 


434 


THE   GASTRO-IXTESTIXAL  CLINIC 


ones,  insomuch  often  that  the  symptoms  are  mostly  removed, 
but  in  the  worst  cases  in  which  the  hgaments  that  support  the 
displaced  organ  have  become  greatly  elongated,  a  complete  cure 
cannot  be  promised,  unless  by  means  of  surgery.  When  there 
is  a  complicating  dilatation,  intragastric  electricity  should  be  of 


Fig.  56. — Area  of  tympanj'  in  case  of  gastroptosis.     Author's  case. 

the  greatest  service  both  for  its  directly  stimulating  action  upon 
the  weakened  gastric  muscles,  and  also  for  its  toning  effect 
upon  all  the  structures  involved  through  its  stimulant  influence 
upon  the  sympathetic  ganglia  behind  the  stomach. 

Treatment — The  same  methods  of  therapy  advised  for  gas- 
tric dilatation  are  worthy  of  trial  in  gastroptosis,  and  if  the 
strengthening  mechanical  measures  already  described  are  per- 
sisted with  long  enough,  virtual  cures  can  be  effected  in  the 


SPLANCHNOPTOSIS  435 

majority  of  cases  (excluding  those  in  which  adhesions  hold 
the  stomach  down),  and  symptomatic  cures  in  all  except  pos- 
sibly some  of  the  very  aggravated  ones  which  are  of  long 
standing.  For  these  such  ingenious  operations  as  that  devised 
by  Beyea  are  doubtless  to  be  advised,  especially  in  the  case  of 
persons  who  are  not  in  a  position  to  avail  themselves  of  pro- 
longed treatment,  and  would  find  it  probably  impracticable  to 
have  the  abdomen  strapped  with  strips  of  adhesive  plaster  every 
four  or  six  weeks,  as  described  in  Lecture  XL.,  under  the  head 
of  Displaced  or  Alovable  Kidney.  Abdominal  surgery  is  be- 
coming constantly  safer  with  the  increasing  skill  of  those  who 
practice  it,  and  it  is  not  at  all  improbable  that  it  will  yet  be  the 
preferable  method  of  treating  the  more  stubborn  cases;  but  at 
present  the  average  patient  afflicted  with  a  chronic  and  intract- 
able displacement  of  one  or  more  of  the  abdominal  organs, 
would  prefer  to  depend  upon  elastic  belts  or  specially  devised 
corsets  and  strapping  with  adhesive  plaster,  which  will  usu- 
ally relieve  the  symptoms,  rather  than  incur  the  risks  of  a  celi- 
otomy for  a  disease  which  does  not  ordinarily  endanger  life. 

For  the  report  of  a  pronounced  case  of  gastroptosis  virtu- 
ally cured  by  mechanical  treatment,  see  Lecture  XLIV. 

Volvulus  of  the  Stomach. — In  the  English  translation  of 
Riegel's  "  Diseases  of  the  Stomach  "  (Philadelphia,  1903),  Dr. 
Charles  G.  Stockton,  the  editor,  interpolates  the  following  note 
in  the  article  upon  Changes  in  the  Position  and  Form  of  the 
Stomach :  '"  The  stomach  sometimes  becomes  twisted  upon  its 
axis,  producing  a  state  that  may  be  called  volvulus  of  the  stom- 
ach, an  instance  of  which  has  been  reported  by  Wiesinger. 
Beck  [Berg,  the  name  should  be]  also  has  two  cases  in  which 
he  confirmed  his  diagnosis  by  operation,  resulting  in  the  com- 
plete cure  of  the  patients." 

Streit,  in  1906,  reported  a  fatal  case  of  volvulus  in  an  insane 
patient  confined  in  the  Connecticut  Hospital  for  the  Insane. 

C.  D.  Spivak  of  Denver  contributed  to  American  Medi- 
cine of  October  31,  1903,  an  interesting  paper  on  the  sub- 
ject.    Li  this  he  made  an  exhaustive  study  of  the  literature, 


43^  THE    GASTRO-INTESTINAL    CLINIC 

which  includes  reports  of  eight  cases  of  the  kind.  Four  of  the 
patients  died  without  any  attempt  at  operative  intervention 
having  been  made,  and  at  an  autopsy  it  was  discovered  that  the 
stomach  had  become  twisted  upon  itself  in  such  a  way  that  its 
orifices  were  obstructed,  and  in  several  of  them  portions  of  the 
intestines,  as  well  as  sometimes  the  omentum,  had  been  forcibly 
displaced  and  involved  in  the  torsion.  In  two  of  these  cases 
there  were  hour-glass  contractions,  and  in  several  either  a  tu- 
mor or  ulcers  or  cicatrices  of  former  ulcers  in  one  or  more  of 
the  orifices.  The  four  others  were  operated  with  a  fatal  result 
in  one  and  recovery  in  the  remainder.  The  findings  were  sim- 
ilar to  those  in  the  first  four  mentioned,  the  stomach  having 
been  twisted  more  or  less  completely  upon  itself  in  all,  and  in 
most  of  the  cases  either  the  omentum  or  some  portions  of  the 
intestines,  or  both,  w'ere  displaced,  torn,  twisted,  or  otherwise 
involved  in  the  tangle. 

During  life  the  symptoms  were  pain,  vomiting  of  an  ex- 
tremely severe  and  obstinate  type,  restlessness,  prostration,  and 
generally  complete  obstipation — the  symptoms,  in  short,  of 
obstruction  of  the  bowels,  including  in  most  cases  great  abdom- 
inal distention  and  tympany.  Attempts  to  empty  the  stomach 
with  the  tube  were  made  in  several  of  the  cases,  but  generally 
failed.  Other  medical  measures  seemed  to  be  quite  useless. 
The  operation  performed  consisted  of  an  incision  through  the 
abdominal  walls,  b}^  means  of  which  alone  in  some  of  the 
cases  the  volvulus  could  be  reduced,  Ijut  in  most  of  them  it  was 
necessary  to  open  the  stomach  also,  so  as  to  relieve  the  disten- 
tion, before  the  reduction  could  be  effected. 

Hour-Glass  Contraction. — This  is  a  condition  of  much  inter- 
est medically  as  well  as  surgically,  though  no  medical  measures 
are  of  any  value  in  overcoming  it.  It  may  be  either  congenital 
or  accjuired,  most  frequently  the  latter.  Its  usual  cause  is 
ulceration,  extending  a  considerable  part  of  the  way  around  the 
stomach  in  its  middle  portion,  or  a  short  distance  above 
the  antrum  pylori.  It  is,  therefore,  a  sequel  of  gastric 
ulcer.    The  subsequent  contraction  divides  the  viscus  into  two 


SPLANCHNOPTOSIS  437 

more  or  less  unequal  parts.  Other  rarer  causes  are  cancer, 
inflammatory  adhesions  of  the  stomach  to  neighboring  organs, 
and,  very  much  more  rarely,  if  ever  efiicient  in  this  way,  corro- 
sive gastritis.  Tight  lacing  has  enough  other  sins  to  answer 
for,  and  I  do  not,  therefore,  care  to  follow  Riegel  in  even  sug- 
gesting that  it  may  be  a  possible  additional  cause  of  hour-glass 
contractions,  especially  since  it  is  a  very  improbable  one.  This 
affection  is  not  likely  to  produce  any  symptoms  in  the  milder 
cases,  and  is  then  very  difficult  to  diagnosticate;  but  in  the 
severer  forms  in  which  the  contraction  is  very  marked,  the 
upper  part  becomes  in  time  dilated  with  the  usual  symptoms  of 
tliat  condition..  The  diagnosis  in  such  marked  cases  can  often 
be  made  after  inflation  by  the  peculiar  figure  formed  by  the  dis- 
tended stomach.  Riegel  gives,  as  a  means  of  diagnosing  even 
mild  cases,  the  fact  that  a  splashing  sound  may  be  obtained 
after  an  attempt  to  empty  the  A'iscus  by  the  tube  has  failed; 
but  this  could  scarcely  be  a  certain  diagnostic  sign,  since  the 
splash  may  at  times  be  elicited  over  the  transverse  colon  or 
cecum,  when  these  are  much  relaxed  and  dilated.  Stockton,  in 
the  American  edition  of  Riegel  already  cited,  mentions  a 
much  more  certain  sign,  which  should  be  decisive  when  it  can 
be  obtained.  In  a  suspected  case  he  empties  the  first  portion 
of  the  stomach  with  the  tube  and  then  manipulates  the  abdomen, 
so  as  to  cause  some  of  the  contents  of  the  second  cavity  to  pass 
into  the  first.  This  fluid  can  then  be  extracted,  and  will  usually 
show  different  reactions  from  the  first,  demonstrating  that  it 
has  been  taken  from  a  different  cavity.  Then,  after  having  the 
tube  arrested  at  the  constriction,  Stockton  has  sometimes  suc- 
ceeded in  coaxing  it  through  into  the  second  portion,  which 
would  be  strong  evidence  of  a  stomach  divided  by  some  sort  of 
a  contraction.  As  stated  above,  the  only  remedy  for  the  con- 
dition is  a  surgical  operation. 

Abnormally  Small  Stomachs — Microgastria. — The  stom- 
ach may  be  abnormally  small  as  well  as  large.  This  condition 
is  likely  to  be  found  after  a  long  period  of  partial  starvation 
or  prolonged  fasts,  and  after  contraction  of  the  cardia  has 


438  THE    GASTRO-INTESTINAL    CLINIC 

existed  for  some  months.  It  may  usually  be  demonstrated  by 
percussion  after  a  full  inflation  of  the  viscus,  except  when  the 
c^rdia  is  obstructed,  but  in  the  latter  cases  can  only  be  inferred. 

CONGENITAL   ANOMALIES   OF  THE   STOMACH 

Various  abnormalities  of  the  stomach  occur  at  times  con- 
genitally.  Among  these  the  forcstomach  is  really  a  widened 
or  sacculated  condition  of  the  lower  part  of  the  esophagus. 
^^^len  the  extreme  end  of  the  esophagus  adjacent  to  the  cardia 
and  below  the  diaphragm  is  congenitally  dilated,  it  is  called 
an f rum  cardiacuui.  These  anomalies  are  not  infrequent  and 
generally  produce  no  symptoms,  but  Riegel  is  authority  for  the 
statement  that  when  coarse  particles  of  food  become  lodged 
in  such  pouches,  serious  symptoms  may  result. 

Hour-glass  contraction  of  the  stomach  has  already  been 
described  as  an  acquired  abnormality  which  results  usually 
from  the  cicatrization  of  an  extensive  ulcer,  but  a  similar  con- 
dition is  sometimes  encountered  as  a  congenital  anomaly.    • 

The  stomach  at  birth  may  also  present  various  abnormalities 
as  to  size  and  form,  most  of  which  are  not  of  much  clinical 
importance. 

Congenital  Stenosis  of  the  Pylorus  is,  however,  a  condition 
which  is  serious  and  seems  to  be  comparatively  common.  Nu- 
merous reports  of  such  cases  have  appeared  recently  in  medical 
literature. 

Shaw  ^  has  found  records  of  between  thirty  and  forty 
authentic  cases,  and  many  others  have  doubtless  been  unrecog- 
nized, the  resulting  deaths  having  been  attributed  to  marasmus, 
etc.  The  children  are  usually  otherwise  normal  at  birth.  They 
show  no  symptoms  until  they  are  from  a  few  days  to  a  few  weeks 
old,  when  vomiting  sets  in  and  nearly  always  proves  fatal — in 
most  cases  within  two  or  three  weeks,  but  sometimes  not  till 
after  several  months.  At  autopsy  the  stomach  is  usually  found 
dilated,  the  intestines  empty  and  collapsed.  The  pylorus  is 
thickened  to  about  half  an  inch,  from  two-thirds  to  one  inch 

'  Brooklyn  Med.  Jour.,  May,  1903. 


SPLANCHNOPTOSIS  439 

long,  exceptionally  resistant  and  usually  of  conical  form.  The 
lumen  is  greatly  diminished,  barely  admitting  a  small  probe  in 
typical  cases,  and  generally  impervious  to  licjuids.  In  a  case 
reported  by  Schwyzer,^  a  microscopic  examination  of  sections 
of  the  pylorus  showed  all  the  layers  exceptionally  thick  and  the 
circular  muscular  layer  greatly  hypertrophied. 

In  some  cases  characterized  by  recurrent  spells  of  incoercible 
vomiting  beginning  soon  after  birth,  the  attacks  will  at  first 
yield  to  treatment,  showing  that  the  stenosis  is  incomplete 
except  when  aggravated  by  spasm  or  inflammatory  swelling. 

This  affection  is  highly  important  for  pedologists  and  gen- 
eral practitioners,  since  it  is  nearly  always  fatal  sooner  or  later, 
unless  recognized  and  surgical  intervention  invoked. 

Treatment,  by  small  doses  of  calomel  and  very  careful  diet — 
especially  small  and  frequent,  feedings  with  the  most  digestible 
or  predigested  liquid  foods — assisted,  when  necessary,  by 
lavage,  have  often  effected  apparent  cures,  when  the  stenosis 
has  been  incomplete,  but  in  time,  a  more  stubborn  attack  in 
such  cases  nearly  always  occurs,  and  the  child  finally  succumbs. 

When  a  tumor  can  be  felt  in  the  pyloric  region,  this,  with 
the  symptoms,  should  make  the  diagnosis  easy,  but  obstinate 
vomiting  in  an  otherwi&e  healthy  and  carefully  fed  infant 
should  awaken  your  suspicion  that  a  congenital  stenosis  of  the 
pylorus  may  exist,  and  when  the  vomiting  persists  for  weeks,  in 
spite  of  treatment,  or  frequently  recurs  without  ascertainable 
cause,  an  exploratory  incision  may  properly  be  advised.  The 
risk  of  this  is  small,  and  the  pyloric  stenosis  not  operated  is 
inevitably  fatal  in  the  end. 

'  New  York  Med.  Jour.,  November  27,  1897. 


LECTURE  XLII 

SPLANCHNOPTOSIS,    CONTINUED— DIS- 
PLACEMENTS OF   THE    COLON 

Coloptosis. — Displacements  of  the  colon  in  various  direc- 
tions are  exceedingly  prevalent — much  more  so  than  is  usually 
supposed.  You  will  easily  demonstrate  the  truth  of  this  state- 
ment by  applying  in  your  practice  the  instructions  given  in 
this  series  of  lectures  concerning  the  determination  of  the 
boundaries  of  the  viscera  and  the  diagnosis  of  abnormalities  in 
them.  Hitherto  most  cases  of  colonic  displacement  have  not 
been  recognized  during  life,  but  in  the  records  of  autopsies  in 
the  hospitals  of  the  world  large  numbers  of  them  have  been 
recorded.  Among  the  most  valuable  of  such  reports  was  one 
contributed  at  my  request  to  the  International  Medical  Maga- 
zine (March,  1901)  by  Dr.  W.  AVayne  Babcock,  one  of  the 
ablest  of  the  younger  surgeons  of  Philadelphia,  at  a  time  when 
he  was  assisting  me  in  editing  that  journal.  The  paper  was 
entitled  Common  Anomalies  of  the  Colon.  Both  by  the 
condensed,  but  nevertheless  graphic,  descriptions  and  by  the 
illustrations  of  various  singularly  bizarre  dislocations  of  the 
colon  which  it  contains,  it  exemplifies  most  strikingly  the  im- 
portance of  the  subject,  besides  shedding  much  light  upon 
it,  and  with  Dr.  Babcock' s  consent  I  have  reproduced  below  his 
valuable  article  in  full.  The  curious  circumstance  noted  by 
Dr.  Babcock,  that  in  none  of  the  seven  cases  of  coloptosis 
described  and  figured  by  him  was  there  observed  any  gas- 
troptosis  or  gastrectasis,  is  very  remarkable  considering  the 
extreme  frequency  with  which  such  abnormal  conditions  are 
usually  found  in  life  associated  with  displaced  colons.  The 
most  reasonable  explanation  for  this  is,  that  either  these  cases 

440 


SPLANCHNOPTOSIS  44I 

were  most  anomalous  in  this  respect  as  well  as  in  the  extraor- 
dinary positions  of  the  colon,  or  else  that  there  had  been  dis- 
placements of  the  stomach  which  were  overcome  by  the  dorsal 
decubitus  and  limited  dietary  during  the  final  illness.  It  is 
believed,  too,  that  even  very  much  enlarged  stomachs  may 
often  undergo  considerable  atrophy  during  the  protracted  ill- 
ness preceding  death,  when  very  little  food  is  taken  or  retained 
for  weeks  or  months. 

''Of  the  viscera  for  which  fixed  positions  are  accepted, 
probably  none  shows  deviations  from  the  usual  location  so 
frequently  as  does  the  colon.  Many  of  these  anomalies  of 
position  are  clearly  explained  by  imperfections  in  the  develop- 
mental process  of  this  part  of  the  intestine.  Originating  as 
a  portion  of  a  simple  tube,  the  early  position  of  the  colon  is 
nearly  vertical ;  the  primitive  cecum  lying  above.  The 
developing  small  intestines,  however,  soon  push  the  colon  to 
the  left  side  of  the  abdominal  cavity.  At  first,  as  the  ab- 
dominal walls  are  too  imperfect  to  retain  all  of  the  intestines, 
a  portion  including  the  cecum  lies  through  the  umbilical  open- 
ing, and  without  the  splanchnic  cavity.  A\^ith  the  develop- 
ment of  the  anterior  parietes  the  cecum  recedes  into  the 
abdomen,  and  from  a  relative  position  below  and  to  the  left 
it  finally  passes  above  and  anterior  to  the  duodenum  to  the 
right  hypochondrium,  where  it  turns  downward  to  its  final 
position  in  the  right  inguinal  region.  This  partial  rotation 
of  the  large  bowel  forms  the  transverse  and  descending  por- 
tions of  the  colon  and  is  accompanied  by  a  compensatory 
partial  rotation  of  the  small  intestines  to  the  left.  An  absence 
1  of  the  ascending  or  of  the  ascending  and  the  transverse  colon, 
the  presence  of  the  cecum  upon  the  left  side  or  in  the  sac  of 
a  congenital  inguinal  hernia,  are  conditions  satisfactorily  ex- 
plained as  due  to  the  failure  of  the  colon  to  complete  this 
rotation  or  even  to  re-enter  the  abdominal  cavity  during  the 
process  of  development.  Treves  suggests  that  incomplete 
rotation  of  the  colon  often  results  from  the  binding  effect  of 
adhesions  following  a  fetal  peritonitis. 


442  THE    GASTRO-IXTESTINAL    CLIXIC 

"  Much  more  common  are  the  alterations  in  position  and  in 
the  form  of  accessory  loops  and  tortuosities,  that  seem  chiefly 
t®  be  due  to  an  increase  in  the  total  length  of  the  colon,  a  lack 
of  equable  distribution  of  length  in  its  various  portions,  or  to 
the  abnormal  mobility  permitted  by  a  mesentery  of  unusual 
length. 

"  The  length  of  the  large  bowel  is  said  to  vary  normally 
between  thirty-nine  and  seventy-eight  inches,  and  apparently 
these  variations  bear  no  definite  relationship  to  the  size  and  gen- 
eral development  of  the  individual,  or  to  the  length  of  the  small 
intestine.  The  relative  lengths  of  its  constituent  portions  are 
also  subject  to  wide  variations  without  the  production  of  evi- 
dent abnormality.  Disproportion  without  the  normal  range 
may  result,  however,  from  the  persistence  of  a  fetal  type  in  the 
adult.  Thus,  in  the  fetus  the  sigmoid  is  greatly  exaggerated 
and  attains  a  length  of  ten  inches.  Should  the  sigmoid,  after 
birth,  keep  pace  with  the  growth  of  the  rest  of  the  bowel,  it  is 
evident  that  it  would  soon  exceed  its  normal  length  in  the  adult 
of  seventeen  inches.  Such  a  progressive  growth  associated 
with  an  elongated  meso-sigmoid  is  probably  an  important 
factor  in  the  formation  of  the  unusually  long  and  displaced 
sigmoids  that  are  so  frecjuent. 

"  The  transverse  colon  is  also  subject  to  wide  variations  in 
length,  and  considering  its  lax  attachments  it  is  not  surprising 
that  deviations  from  its  usual  transverse  course  are  common. 
The  cecum  shows  deviations  in  position  and  direction  more 
frequently  than  does  the  ascending  colon,  while  congen- 
ital anomalies  of  the  descending  colon  are  practically  never 
seen. 

"  Displacements  or  elongations  of  portions  of  the  colon  may 
also  be  the  result  of  acquired  causes,  such  as  the  overloading 
or  overdistention  of  the  bowel,  the  traction  resulting  from 
adhesions,  and  the  pressure  from  displaced  or  enlarged  organs 
or  from  tumors.  In  none  of  the  cases  here  recorded,  which 
illustrate  common  types  of  deviation  in  the  course  of  the  colon, 
was  such  an  acquired  cause  apparent.     In  no  case  was  the 


SPLANCHNOPTOSIS  443 

condition  diagnosed  during  life,  nor  was  it  evident  that  the 
lesion  of  the  colon  was  in  any  case  responsible  for  the  fatal 
result.  Unfortunately,  the  clinical  notes  describing  the  ab- 
dominal symptoms  are  found  to  be  very  incomplete.  The 
frequent  occurrence  of  these  anomalies  is  shown  by  the  fact 
that  the  seven  well-marked  cases  here  described  occurred  in 
thirty  consecutive  necropsies  which  I  held  at  the  Philadelphia 
Hospital  during  November  and  December,  1900.  Indeed, 
marked  deviations  from  the  usual  course  of  the  colon  are  so 
common  and  so  frequently  are  without  very  evident  symptoms, 
that  it  is  not  improbable  that  a  proportion  of  the  reported  cases 
of  severe  abdominal  disorder  attributed  to  this  cause  may  have 
been  founded  upon  a  coincidence  rather  than  a  true  setiologic 
relation.  Conversely,  it  is  probable  that  obstinate  constipa- 
tion, tympany,  and  other  abdominal  symptoms  of  obscure 
setiolog}^  may  depend  in  quite  a  proportion  of  cases  upon  the 
elongation,  displacement,  or  tortuous  course  of  portions  of  the 
colon.  In  the  investigations  for  disease  of  the  upper  intestinal 
tract  the  condition  of  the  large  bowel  seems  frequently  to  be 
neglected. 

"  The  precise  diagnosis  of  anomalies  of  the  colon  is  often 
difficult.  Careful  abdominal  percussion,  aided  by  the  inflation 
of  the  bowel  through  the  rectum  by  water  or  gas,  may  fre- 
quently fail  accurately  to  outline  the  colon,  especially  when 
there  is  a  marked  and  complicated  deflection.  In  certain  cases 
the  position  of  the  colon  is  very  accurately  shown  by 
skiagraphs  taken  after  the  large  bowel  has  been  filled  with  an 
emulsion  of  bismuth-subnitrate  or  other  substance  with  a  sim- 
ilar resistance  to  the  x-rays. 

"  Abnormalities  of  the  colon  may  often  interfere  with  the 
diagnosis  of  other  abdominal  disorders.  Thus,  in  Case  I.  it 
would  have  been  very  difficult  to  outline  the  stomach  by  the 
conventional  methods,  as  it  was  behind  a  greatly  dilated  por- 
tion, of  the  sigmoid  flexure.  Such  a  dilatation  might  readily 
have  been  mistaken  for  a  dilated  stomach.  The  introduction 
of  liquids  or  gases  into  the  stomach  would  probably  have  had 


444  THE    GASTRO-INTESTINAL    CLINIC 

little  effect  upon  the  physical  signs ;  while  the  introduction  of  a 
rectal  tube  might  have  reduced  the  area  of  tympany. 

t "  It  has  been  asserted  that  the  diagnosis  between  enlarge- 
ments or  tumors  of  the  spleen  or  left  kidney  may  be  accurately 
determined  by  inflating  the  descending  colon  and  ascertaining 
its  relation  to  the  enlargement.  This  assumes  that  the  trans- 
verse colon  has  its  line  of  attachment  external  to  the  left 
kidney,  and  that  the  splenic  flexure  lies  below  and  internal  to 
the  spleen.  Assuming  that  this  relation  is  always  borne  out 
in  enlargement  of  these  organs,  it  is  evident  that  in  cases 
similar  to  I.,  II.,  III.,  or  IV.,  the  entrance  of  gas  through  the 
rectum  would  chiefly  distend  the  elongated  and  displaced 
omega  loop,  which  would  almost  certainly  be  mistaken  for  the 
descending  colon.  The  frequency  of  these  deviations  of  the 
sigmoid  would  indicate  the  unreliability  of  the  method, 
especially  in  those  cases  in  which  the  colon  is  found  only 
internal  to  or  below  the  new  growth. 

"  In  many  cases  the  malformation  interferes  so  slightly 
with  the  normal  physiology  of  the  large  intestines  that  little  or 
no  treatment  is  required.  When  the  symptoms  are  more 
severe,  various  therapeutic  measures  will  suggest  themselves 
upon  the  determination  of  the  character  of  the  abnormality. 
In  obstinate  cases  of  a  severe  type,  surgical  intervention  has, 
in  isolated  cases,  given  very  encouraging  results,  and  deserves 
a  wider  trial.  Of  the  surgical  measures  the  methods  of 
anastomosis  or  resection  of  portions  of  the  colon,  when 
feasible,  are  to  be  preferred  to  the  commonly  employed 
colotomy  with  its  ensuing  discomforts. 

"  It  is  significant  that  in  not  one  of  the  following  cases  was 
there  a  gastroptosis  or  gastrectasis,  nor  was  a  single  case 
noticed  in  the  series  of  thirty  necropsies. 


"  Case  I.  Russian,  male,  tailor,  aged  fifty,  was  admitted 
December  12,  1900,  and  had  suffered  from  cough,  expectora- 
tion, and  progressively  increasing  weakness  for  the  past  three 
months.     The  chest  and  abdomen  are  greatly  emaciated,  the 


SPLANCHNOPTOSIS 


445 


temperature  is  of  the  hectic  type,  the  urine  contains  hyahn 
casts  and  a  trace  of  albumin.     The  patient  is  constipated. 

"  Necropsy,  December  31,  1900.  The  body  shows  extreme 
emaciation.  The  cecum  hes  in  the  right  inguinal  region  above 
the  brim  of  the  pelvis.     The  colon  passes  upward  for  6  cm. 


I 


Fig.  57. — Case  I.  Anomalous  course  of  the  first  portion  of  the  ascending 
colon.  Unusual  course  and  dilatation  of  the  omega  loop.  Trilobed 
stomach. 


then  bends  upon  itself  and  passes  downward  into  the  pelvis, 
curves  and  returns  upward  to  the  concavity  of  the  right  ileum, 
where  it  forms  a  third  decided  curve  with  its  convexity 
directed  upward.  It  then  ascends  to  the  inferior  surface  of 
the  liver,  becomes  somewhat  distended  and  crosses  transversely 
to  the  spleen.  Diminishing  in  caliber,  it  turns  downward  to 
.the  left  pelvic  brim.     It  now  bends  and  ascends  along  the 


446  THE    GASTRO-IXTESTIXAL    CLINIC 

descending  colon  to  the  diaphragm,  where  it  becomes  greatly, 
dislended,  measuring  12  cm.  in  its  transverse  diameter,  and 
lies  in  front  of  the  preceding  portion,  the  stomach  and  the 
median  portion  of  the  transverse  colon.  It  now  passes  down- 
ward, becomes  constricted  just  above  the  promontory  of  the 
sacrum,  and  enters  the  pelvis.  The  transverse  colon  is  ad- 
herent to  the  liver.  The  stomach  is  narrow  and  rather 
elongated,  with  two  distinct  constrictions  producing  three  lobes. 
The  upper  constriction  is  a  short  distance  below  the  cardia 
and  is  the  more  pronounced.  The  lower  constriction  is  about 
5  cm.  above  the  pylorus.  Below  the  duodenum  the  mucosa 
of  the  intestines  is  the  seat  of  many  ulcers  until  the  dilated 
sigmoid  flexure  is  reached,  where  the  ulcerative  process  ceases. 
The  ulcers  are  rounded,  shallow,  with  necrotic  irregular  bases, 
and  vary  from  a  few  mm.  to  i  cm.  in  diameter.  They  are 
evidently  tubercular.  Associated  lesions  are  those  of  pneu- 
monia, pulmonary  tuberculosis,  and  parenchymatous  degenera- 
tion of  the  kidneys. 

"  Case  II.  German,  male,  laborer,  aged  sixty-nine,  admitted 
December  12,  1900,  complaining  of  pains  in  the  chest,  dyspnoea, 
and  weakness.  The  family  history  was  obscure.  Has  been  ill 
with  cough  and  expectoration  for  a  year.  There  are  evidences 
of  consolidation  of  a  large  portion  of  the  right  lung,  but  signs 
of  abdominal  disease  are  not  found.  The  clinical  diagnosis  is 
phthisis  pulmonalis. 

"  Necropsy  December  24,  1900.  The  body  is  that  of  a  well- 
developed,  but  aged,  white  man.  The  ascending  transverse 
and  descending  portions  of  the  colon  follow  the  conventional 
course.  The  ascending  as  well  as  the  descending  colon  lies 
well  to  the  rear.  The  sigmoid  is  in  the  form  of  a  long  loop, 
which  touches  the  transverse  colon  6  cm.  above  the  umbilicus 
and  to  the  left  of  the  median  line.  The  descending  portion  of 
the  loop  passes  downward  into  the  pelvis.  The  liver  is  4  cm. 
above  the  costal  margin.  Associated  are  the  lesions  of  miliary 
tuberculosis  of  the  right  lung  Avith  bronchiectasis,  marked 
oedema  of  both  lungs,  and  parenchymatous  degeneration  of  the 
kidneys. 

"  Case  III.  Irish,  aged  seventy-two,  housewife,  widow. 
The  patient  was  admitted  April  4,  1899,  complaining  of  burn- 
ing pains  in  the  hand's,  shoulders,  and  ankles.  She  was  free 
from  illness  until  forty  years  of  age,  when  she  had  an  attack 
of  acute  articular  rheumatism.     This  recurred  about  eighteen 


SPLANCHNOPTOSIS 


447 


months  ago,  and  became  chronic.  The  face  is  red  and 
shghtly  puffy,  the  extremities  cedematous,  the  joints  deformed, 
the  skin  shiny.  The  patient  is  constipated.  No  thoracic  or 
abdominal  disease  is  detected.     On  April  lo,  1899,  the  urine 


Fig.  58. — Case  II.     Elongation  and  displacement  of  the  sigmoid  flexure. 


was  negative;  on  December  27,   1900,  before  death,  it  con- 
tained casts  and  a  large  amount  of  albumin. 

*'  The  necropsy,  December  28,  1900,  shows  a  moderate 
amount  of  subcutaneous  fat,  an  exaggerated  sigmoid  loop,  the 
apex  of  which  is  in  contact  with  the  lower  portion  of  the  left 
kidney.  The  intestines  are  otherwise  negative.  The  stomach 
is  small  and  elongated.  There  is  an  associated  right  lobar 
pneumonia,  marked  pulmonary  oedema,  and  parenchymatous 
nephritis.     The  liver  has  a  marked  transverse  furrow,   and 


448 


THE    GASTRO-INTESTINAL    CLINIC 


there  are  several  deep  vertical  grooves  upon  the  anterior  upper 
surface  of  the  right  lobe.  An  accessory  renal  artery  enters 
the  upper  pole  of  the  left  kidney. 

"  Case    IV.    White,    male,    aged    twenty-two.      Admitted 
December  19,  1900,  complaining  of  cough  and  expectoration. 


I 


Fig.  59. — Case  III.     The  sigmoid  loop  touches  the  lower  border  of  the  left 
kidney.     Enlarged  liver  with  marked  transverse  furrow. 


with  pain  in  the  chest  and  abdomen.  Has  suffered  from  pain 
in  the  epigastrium  for  the  past  year.  About  nineteen  days  ago 
had  a  chill,  followed  by  fever  and  sweating.  The  bowels  are 
said  to  be  "  regular.''  (?)  He  is  thin,  pale,  with  crusted  lips; 
dry,  furred  tongue,  and  abdominal  tympany.  The  Widal 
reaction  is  present  and  the  urine  contains  hyahn  and  granular 
casts.     The  clinical  diagnosis  is  typhoid  fever. 


SPLANCHNOPTOSIS 


449 


"  Necropsy,   December  2.y,    1900. 


follow  the  usual  course  until  the  sigmoid  was  reached 


The  colon  is   found  to 
This 

forms  a  much  exaggerated  loop.  It  passes  at  first  upward 
and  to  the  right  until  about  4  cm.  above  and  slightly  to  the 
right  of  the  umbilicus,  where  it  curves  downward  and  to  the 


Fig.  60. — Case  IV.     Exaggerated  and  displaced  sigmoid  loop. 

left  until  it  reaches  the  concavity  of  the  left  ileum,  after  which 
it  passes  almost  directly  downward  to  the  rectum.  The  in- 
testinal adhesions  are  noted.  The  ileum  contains  many  typical 
typhoidal  ulcers.  A  Meckel's  diverticulum  is  present.  The 
spleen  is  enlarged  and  hypersemic ;  there  are  areas  of  sub- 
mucous ecchymosis  in  the  renal  pelvis.  The  lungs  show  a 
congestive  oedema.  The  stomach  is  very  small  and  covered 
by  the  left  lobe  of  the  liver.  Its  position  is  nearly  vertical,  the 
cardia  being  above  and  only  2  cm.  to  the  left  of  the  line  of 
the  pylorus. 


450 


THE    GASTRO-INTESTINAL    CLINIC 


"  Case  V.  White,  male,  aged  thirty-three,  cigar-maker,  of 
rather  dissolute  habits,  admitted  December  lo,  1900,  having 
suffered  for  the  past  month  with  a  pleuro-pneumonia.  On  ad- 
mission there  was  "  shifting "  dullness  over  the  lower  left 
thorax,     A  considerable  quantity  of  pus  intermixed  with  air 


Fig.  61. — Case  V.     V-shaped  course  of  the  transverse  colon.     The  appen- 
dix lies  behind  the  cecum  within  the  layers  of  the  meso-cecum. 

was  withdrawn  by  aspiration  of  left  thorax.  A  few  days  later 
the  man  died.  No  notes  relative  to  the  gastro-intestinal  con- 
dition are  found. 

"  Necropsy,  December  14,  1900.  The  body  shows  a  fair 
muscular  development  and  is  sixty-eight  inches  in  height. 
The  mesentery  covers  the  small  intestines.  The  transverse 
colon  forms  the  letter  V,  its  apex  being  at  the  umbilicus.  The 
hepatic  and  splenic  curves  are  in  their  usual  positions.  The 
appendix  lies  behind  the  cecum,  between  the  folds  of  the  meso- 


SPLANCHNOPTOSIS 


451 


cecum.  The  predominant  lesions  include  a  large  subpleural 
pulmonary  cavity  of  the  left  lower  lobe  with  associated  atelec- 
tasis, and  a  localized  hydrothorax.  There  is  a  chronic 
miliary  tuberculosis  at  the  apex  of  the  lungs.  The  kidneys 
show  cloudy  swelling. 

"  Case  VI.  American,  white,  housewife,  aged  thirty-eight. 
Her  father  died  of  intestinal  tuberculosis.     The  patient  on  ad- 


FiG.  62.— Case  VI.     Exaggerated  V-shaped  course  of  the  transverse  colon. 
The  liver  is  enlarged  from  a  fatty  infiltration. 


mission,  September  13,  1900,  was  thin  and  anaemic  and  suf- 
fered from  extensive  surface  burns  received  about  two  months 
before.  There  was  also  a  watery  diarrhea  and  abdominal 
tenderness.     The   temperature   was   hectic.     The  patient   de- 


452 


THE    GASTRO-INTESTINAL    CLINIC 


veloped  delirium  and  died  about  three  months  after  admission. 
The  chnical  diagnosis  was  intestinal  ulceration. 
1  "  Necropsy,  December  6,  1900.  The  body  is  sixty-one 
inches  in  length  and  shows  a  moderate  degree  of  emaciation. 
The  subcutaneous  abdominal  fat  was  25  mm.  in  thickness. 
The  abdominal  muscles  were  poorly  developed.     Beginning  in 


Fig.  63.— Case  VII.     Anomalous  direction  of  the  transverse  colon. 


the  right  iliac  fossa,  the  colon  ascends  in  the  usual  manner  to 
the  inferior  surface  of  the  liver ;  it  then  turns  downward  and 
inward  to  the  pubes,  from  which  it  ascends  to  the  left  inferior 
costochondral  junction  and  bends  transversely  inward,  forming 
the  sigmoid  flexure.  The  omentum  hangs  below  the  colon  and 
is  adherent  at  one  point  to  the  uterus.     The  intestines  are  not 


SPLANCHNOPTOSIS  453 

adherent  and  are  apparently  free  from  other  gross  lesions.  The 
stomach  is  so  small  and  contracted  as  to  resemble  intestine. 
It  measures  5x25  cm,,  and  its  mucosa  contains,  near  the 
pylorus,  a  rounded  undermined  ulcer  2-3  mm.  in  diameter. 
The  predominant  lesions  are  miliary  tuberculosis  of  the  lungs, 
left  pleura,  and  spleen;  fatty  infiltration  of  the  liver  and 
parenchymatous  degeneration  of  the  kidneys. 

"  Case  VII.  White,  housewife,  aged  thirty-one,  height  five 
feet,  and  of  fair  development,  was  admitted  to  the  hospital 
December  12,  1900,  sufifering  from  weakness,  depression,  and 
delusions  of  persecution.  These  symptoms  had  appeared  after 
the  curettement  of  the  uterus  five  weeks  previous  to  admission. 
No  abdominal  abnormalities  were  noticed,  but  special  notes 
relative  to  the  intestinal  tract  were  not  taken.  The  urine  con- 
tained albumin  and  casts.  The  patient  sank  and  died.  The 
clinical  diagnosis  was  uraemia. 

"  Necropsy,  December  24,  1900.  The  mesentery  is  found 
above  the  colon.  The  cecum  is  in  its  usual  position,  and  the 
■ascending  colon  ascends  nearly  vertically  to  the  liver,  where 
the  colon  bends  abruptly  upon  itself  and  returns  along,  and 
internal  to  the  first  portion  until  the  cecum  is  reached,  where 
it  again  sharply  turns  and  passes  upward  to  the  ensiform 
appendix.  Here  the  colon  again  turns  downward  and  some- 
what outward  to  the  hollow  of  the  ileum,  where  it  turns  trans- 
versely inward,  becoming  continuous  with  the  sigmoid  flexure. 
No  lesions  of  the  stomach  or  small  intestines  are  found.  There 
were  no  adhesions.  The  kidneys  are  apparently  the  seat  of  a 
parenchymatous  degeneration." 

The  Symptoms  of  Coloptosis. — What  is  said  in  Lecture 
XLIII.  concerning  the  symptoms  of  dislocations  of  the  small  in- 
testines applies  with  equal  force  to  those  of  the  colon.  Consti- 
pation is  the  most  frequent  one,  but  may  sometimes  be  replaced 
by  diarrhea,  and  when  the  displacement  is  decided,  one  of  these 
is  usually  present,  though  in  exceptional  cases  the  bowels  may 
act  normally.  Mucous  colitis  has  been  said  to  be  a  constant 
symptom,  but  this  is  not  true.  Dragging  sensations  in  the 
lower  abdomen,  flatulency,  colics,  and  all  grades  or  forms  of 
minor  discomfort  in  the  same  region  may  occur.  After  read- 
ing Dr.   Babcock's  paper  and  especially  noting  the  extraor- 


454  THE    GASTRO-INTESTINAL    CLINIC 

dinary  contortions  which  the  colon  is  capable  of  making,  we 
cannot  be  surprised  that  patients  whose  large  bowels  have 
never  been  mapped  out  and  therefore  may  be  as  badly  dis- 
placed, should  complain  of  persistent  abdominal  pains  and 
derangements  in  spite  of  all  sorts  of  remedial  measures  em- 
pirically applied.  It  should  lead  us  to  see  the  necessity  of 
determining  with  the  greatest  possible  care  the  position  and 
course  of  the  colon  in  any  obscure  case  of  abdominal  trouble 
in  which  our  investigations  of  the  other  organs  have  not 
helped  us  to  a  satisfactory  diagnosis  and  treatment. 

Diagnosis. — It  is  exceedingly  rare  that  an  anomalous 
position  of  that  viscus  itself  or  of  any  neighboring  organ  could 
prevent  a  well-trained  diagnostication  from  determining  the 
boundaries  of  the  stomach,  and  this  having  been  done,  the 
position  of  even  a  badly  twisted  or  displaced  colon  should  be 
made  out  as  a  rule  by  inflating  it  first  with  warm  water  and 
later  with  air  or  other  gas,  especially  when  both  the  stomach 
and  colon  have  previously  been  emptied.  But,  if  percussion 
with  these  helps  should  fail,  you  should  try  to  pass  through 
the  whole  course  of  the  colon  a  very  flexible  metal  bougie,  such 
as  the  cable  of  Turck's  gyromele  or  of  my  intragastric  elec- 
trode, which  could  easily  be  palpated,  and  then,  if  necessary, 
have  made  a  radiograph  of  the  colon  with  this  in  situ.  This 
would  show  all  the  possible  sinuosities  and  the  position  of 
them.  As  Dr.  Babcock  says,  there  would  be  difficulty  in  the 
worst  of  the  above  described  cases  in  inflating  the  entire  colon 
with  gas,  but  a  cable  of  suitable  flexibility  could  nearly  always 
be  introduced. 

Treatment. — The  various  hygienic  and  mechanical  meas- 
ures which  I  have  already  described  to  you,  as  helpful  in  over- 
coming the  malpositions  of  the  other  viscera,  may  often  suf- 
fice to  overcome  displacements  of  the  colon.  Long  percus- 
sive sparks  from  the  static  machine  and  the  interrupted  electric 
current  (faradism)  can  effect  much  in  bringing  up  the  nerve 
tone  generally  and  still  more  by  strengthening  the  muscles  of 
the  abdominal  wall  and  of  the  visceral  walls — perhaps  also 


SPLANCHNOPTOSIS  .  455 

the  tone  of  the  supporting  ligaments.  Massage  skillfully 
apphed  helps  decidedly  in  the  same  direction,  as  do  also  rowing 
and  the  special  exercises  for  the  abdominal  muscles  which 
were  described  in  Lecture  XXIII. ,  and  various  hydriatic  pro- 
cedures, especially  jets  of  hot  and  cold  water  directed  against 
the  bare  abdomen.  Whatever  may  be  their  modus  operandi, 
it  is  certain  that  a  course  of  treatment  embracing  several  of 
these  methods  properly  carried  out  results  nearly  always  in 
decidedly  elevating  the  displaced  viscera,  including  usually  the 
colon,  and  not  infrequently  entirely  overcome  the  displacement. 

For  patients  who  cannot  have  such  a  thorough  course  of 
curative  treatment  the  most  complete  and  effectual  palliative 
relief  possible  can  be  afforded  by  the  method  of  strapping  the 
abdomen  described  in  Lecture  XL.,  under  the  head  of  The 
Treatment  of  Movable  Kidneys;  and  holding  the  displaced 
parts  well  up  for  months  at  a  time,  by  means  of  such  strap- 
ping, should  conduce  much  toward  a  cure.  In  stubborn  cases 
which  are  causing  serious  symptoms,  surgical  intervention  may 
be  necessary  and  justifiable. 

Reed  and  Robinson  ^  reported  50  cases  of  gastroptosis  in 
tuberculous  patients  seen  in  the  Pottenger  Sanitarium  in  Mon- 
rovia, Cal.,  in  1907  and  1908.  These  were  treated  mainly  by 
diet  and  rest  with  the  other  usual  remedies  for  tuberculosis, 
and  also,  in  addition,  strapping  with  adhesive  plaster  or  spe- 
cial abdominal  supporters  for  those  out  of  bed.  The  results 
were  very  satisfactory  in  nearly  all  the  cases,  the  patients  being 
relieved  as  a  rule  of  their  abdominal  symptoms,  and  the  course 
of  the  tuberculosis  was  thereafter  more  favorable. 

1  Gastroptosis  in  Tuberculous  Patients — A  Report  of  Fifty  Cases.  By 
DrS:  Boardman  Reed  and  Frank  Neall  Robinson.  So.  Calif  .Practitioner, 
Nov.  '08. 


LECTURE  XLIII 

SPLANCHNOPTOSIS,  CONTINUED:  DIS- 
PLACEMENTS OF  THE  LIVER,  SPLEEN, 
AND  SMALL  INTESTINES  —  GENERAL 
CONSIDERATIONS  CONCERNING  DIS- 
PLACEMENTS AND   DILATATIONS 

Not  more  than  a  very  brief  account  will  be  given  here  of  the 
ptoses  of  the  liver  and  spleen,  which  have  comparatively  little 
to  do  with  diseases  of  the  stomach  and  intestines.  There  are 
no  characteristic  symptoms  by  which  you  may  be  able  certainly 
to  recognize  or  differentiate  any  of  the  above-named  displace- 
ments. This  can  only  be  done  by  means  of  the  physical  signs. 
The  symptoms  produced  by  them  are  usually  indistinguishable 
from  those  of  gastroptosis,  nephroptosis,  etc. 

Hepatoptosis  is  not  likely  to  cause  any  constant  or  well- 
defined  symptoms,  and,  as  can  be  well  understood,  on  account 
of  its  weight  and  anatomic  position,  the  liver  can  scarcely  sink 
downward  without  causing  the  rig'ht  kidney  at  least,  and  gen- 
erally the  stomach,  to  become  also  displaced.  Any  symptoms, 
therefore,  could  be  attributed  to  the  associated  displacement  of 
the  adjacent  organs.  A  sense  of  weight  or  dragging  sensation, 
more  pronounced  than  would  follow  the  falling  of  the  smaller 
organs,  should  be  expected  and  will  generally  be  encountered 
in  such  cases.  Yet,  by  the  physical  signs,  any  displacement  of 
the  liver  can,  as  a  rule,  be  promptly  ascertained.  So  large  a 
body  can  have  its  boundaries  easily  mapped  out  by  percussion, 
whatever  its  position,  except  in  the  case  of  peculiar  abdominal 
conditions,  such  as  ascites,  an  ovarian  cyst,  tumor  of  the  omen- 
tum adjoining  the  liver  below,  tumor  of  the  right  kidney, 
hydro-thorax  or  hydro-pneumothorax,  perforation  of  the  peri- 

4S6 


SPLANCHNOPTOSIS  457 

tonetim  with  escape  of  gases  into  the  peritoneal  cavity,  etc. 
Those  of  the  above-named  conditions  which  would  be  likely  to 
present  difficulties  in  the  determination  of  the  boundaries  of 
the  liver  are  mostly  complications  of  diseases  of  such  a  serious 
nature  that  an  experienced  diagnostician  would  scarcely  fail  to 
recognize  them,  and  these  diseases  would  be  of  such  paramount 
importance  that  the  presence  or  absence  of  hepatoptosis  at  the 
same  time  would  scarcely  claim  very  much  consideration.  An 
accumulation  of  feces  in  the  right  flexure  of  the  colon,  and 
tumors  adjoining  it  below,  might  cause  a  continuation  of  per- 
cussion dullness,  resembling  that  over  the  liver  on  down  for 
a  little  distance  over  the  abdominal  cavity,  but  it  is  usually  pos- 
sible in  such  cases  to  insinuate  the  fingers  between  the  lower 
edge  of  the  liver  and  the  other  dullness-producing  bodies  when 
the  effort  is  skillfully  and  persistently  made.  Enlargement  of 
the  liver  under  ordinary  circumstances  can  be  readily  differenti- 
ated from  a  displacement  of  it  by  the  increased  area  of  percus- 
sion dullness. 

The  liver  may  be  found  in  various  degrees  of  ptosis,  but  the 
more  marked  grades  of  its  displacement  are  so  extremely  rare 
that  I  have  personally  never  seen  a  case  in  which  the  organ 
sank  further  than  to  a  point  where  its  lower  border  appeared 
two  to  three  inches  below  the  lowest  rib  with  the  patient  in  a 
standing  position,  though  I  am  constantly  meeting  with  dis- 
placed kidneys,  stomachs,  and  intestines  in  a  considerable  pro- 
portion of  which  the  prolapse  is  very  marked.  I  have  almost 
constantly  under  treatment  one  or  more  cases  of  gastroptosis 
in  which  the  stomach  has  descended  as  far  as  it  can  go,  resting 
upon  the  pelvic  organs. 

Movable  Spleen  is  occasionally  encountered  in  consequence 
of  the  elongation  of  the  gastrosplenic  ligament  and  of  the 
blood-vessels  supplying  the  organ,  but  is  a  rare  accident,  and 
has  only  an  incidental  interest  in  this  connection. 

Displacements  of  the  Small  Intestines. — When  there  is 
hepatoptosis  or  marked  gastroptosis,  there  must  be  more  or  less 
enteroptosis ;  both  the  colon  and  small  intestines,  especially  the 


458 


THE   GASTRO-INTESTINAL    CLINIC 


duodenum,  are  almost  necessarily  dislocated  as  a  consequence. 
But  while  the  position  of  the  colon  can  generally  be  determined 
with  an  approach  to  exactness,  it  is  often  difficult  or  impossible 
to  do  the  same  for  the  small  intestines.     The  development  of 


// 


A- 


1 


Fig.  64. — Downward  displacement  of  the  liver  and  intestines.  (Splanch- 
noptosis.) d,  duodenum;  //,  liver;  v,  gallbladder;  <:,  carcinoma  nodule 
on  the  tongue-shaped  prolongation  of  the  hepatic  lobe,  immediately 
above  the  symphysis;  c.tr.,  transverse  colon;  c.d.,  descending  colon;  z, 
ileum.  (From  Prof.  Dr.  C.  A.  Ewald's  "  Krankheiten  des  Darms  und 
des  Bauchfells.") 

obstinate  constipation  following  a  recognized  descent  of  the 
stomach  would,  of  course,  render  it  probable  that  there  was 
a  kink  in  the  intestines  somewhere,  and  this  is  most  frequently 
found  at  the  beginning  of  the  duodenum  near  the  stomach. 
Indeed,  a  marked  falling  of  the  stomach  produces  almost  un- 
avoidably a  flexure  of  the  small  gut  at  this  point.  (See  Fig. 
64,  showing  the  ileum  displaced  into  the  pelvis.) 


SPLANCHNOPTOSIS  459 

The  symptoms  of  a  displacement  of  the  small  intestines, 
besides  constipation,  which  results  in  most  cases,  though  by  no 
means  in  all,  are  deranged  intestinal  digestion  with  discomfort 
some  hours  after  eating,  incarcerated  flatus  with  rumbling, 
gurgling  (borborygmi),  and  colicky  pains.  There  may  be  also 
any  of  the  symptoms  of  neurasthenia.  After  inflating  the 
stomach  and  colon,  and  then  with  the  help  of  percussion,  clap- 
otage,  etc.,  determining  the  position  of  these  viscera  to  be  nor- 
mal or  only  moderately  low,  the  finding  of  marked  tympany 
and  swelling,  or  a  bulging  forward  in  the  lowest  parts  of  the 
abdominal  cavity,  would  be  evidence  that  the  small  intestines 
had  undergone  a  considerable  downward  displacement. 

Treatment. — Many  of  these  ptoses  can  be  decidedly  ame- 
liorated by  the  same  forms  of  treatment  recommended  for 
dilatation  and  displacement  of  the  stomach.  Frequent  manual 
replacements  of  the  prolapsed  organs  while  the  patient  lies  on 
the  back  with  the  hips  raised,  followed  by  vigorous  stimulation 
of  the  abdominal  muscles  through  massage,  electricity,  appli- 
cations alternately  of  hot  and  cold  water,  etc.,  with  daily  exer- 
cise of  the  same  muscles  by  gymnastic  exercises,  and  the 
wearing  of  some  retentive  apparatus,  such  as  either  an  elastic 
abdominal  supporter  or  adhesive  straps  (see  Lecture  XL.) 
between  times,  will  often  accomplish  much  in  the  way  of  im- 
proving the  condition  and  the  removal  of  the  symptoms,  even 
if  they  cannot  always  definitely  cure.  Doubtless,  in  some  of 
these  cases,  as  in  the  worst  of  the  other  displacements,  surgery 
may  yet  be  able  to  acomplish  such  successful  results  and  so 
safely  that  it  will  become  the  proper  resource. 

Then,  of  course,  all  hygienic  measures  which  improve  the 
general  health  and  nerve  and  muscle  tone  must  assist  in  reme- 
dying the  trouble  under  consideration.  Hence,  for  the  stronger 
patients,  active  outdoor  exercise  should  be  prescribed,  such  as 
horseback  riding,  rowing,  golfing,  etc.,  as  well  as  gymnastics  for 
the  abdominal  muscles,  etc.  For  the  weaker  ones,  a  rest-cure  is 
often  more  suitable.  The  induced  electric  current  (faradism), 
locally  applied,  may  usually  be  hopefully  employed  in  all  the 


460  THE    GASTRO-INTESTINAL    CLINIC 

cases.  The  foregoing  measures,  together  with  some  sort  of 
abdominal  support,  will  usually  benefit  greatly  any  form  of 
abdominal  ptosis  and  effect  a  cure  in  many  of  them. 

In  a  paper  which  I  contributed  to  the  Therapeutic  Gazette 
for  September,  1899,  I  discussed  at  length  the  various  ptoses, 
their  causes  and  treatment.  Extracts  from  that  paper  may  be 
usefully  inserted  here  to  emphasize  some  of  the  more  impor- 
tant points  already  sought  to  be  made,  and  also  to  illustrate 
what  can  be  done  in  the  classes  of  cases  mentioned  by  means 
of  medical  and  mechanical  forms  of  treatment.  Following  are 
the  extracts : 

Some  Statistics  of  Displacements,  etc. — "  A  very  large  pro- 
portion of  uterine  flexions  and  versions  in  the  non-child- 
bearing  woman  certainly,  and  probably  also  in  parous  women, 
are  for  the  most  part  a  direct  mechanical  result  of  the  press- 
ure from  above  of  displaced  colons  heavy  with  retained  feces, 
and  low-lying  dilated  or  displaced  stomachs,  which  after  a  full 
meal  may  often  be  found  resting  immediately  upon  the  bladder 
and  uterus. 

"  Displacements  of  the  abdominal  viscera  are  very  much 
more  frequent  in  women  than  in  men.  In  a  large  number  of 
examinations  of  abdomens  of  which  full  records  have  been 
preserved,  made  during  a  period  covering  less  than  three  years, 
and  including  the  cases  of  710  different  persons,  there  were 
362  patients  in  whorn  the  greater  curvature  of  the  stomach 
was  found  at  or  below  the  level  of  the  umbilicus  as  a  result  of 
either  displacement  or  dilatation.  There  were  many  other 
cases  in  which  the  departures  from  the  normal  were  present 
to  a  less  extent.  In  exceedingly  few — in  not  more  than  one 
per  cent. — of  these  362  displacements  and  dilatations  had  the 
condition  been  previously  recognized,  so-  far  as  could  be 
learned. 

"  Of  the  above  mentioned  362  abnormal  stomachs,  122  were 
in  men  and  240  in  women.  Almost  exactly  two-thirds  were 
.thus  in  'the  female  sex  and  only  one-third  in  males.  Of  the 
displacements,  in  which  the  whole  organ  had  descended  instead 


I 


SPLANCHNOPTOSIS  461 

of  a  part  only  having  been  stretched  downward,  the  dispropor- 
tion is  stin  more  stril<ing.  There  were  eighty  of  these,  of 
which  only  twenty  were  in  men,  and  sixty,  or  just  three  times 
as  many,  in  women.  This  is  in  spite  of  the  fact  that  nowadays, 
in  cities  at  least,  outside  of  the  laboring  class,  a  large  propor- 
tion of  men  take  scarcely  more  exercise  than  women,  and  all 
classes  of  men  abuse  their  stomachs  far  more  generally  by  the 
pleasures  of  the  table  and  the  temptations  of  the  dramshop. 
The  conclusion  is  inevitable,  therefore,  that  the  great  prepon- 
derance of  this  trouble  in  the  weaker  sex — weaker  mainly 
because  of  their  hygienic  faults — is  due  largely  to  the  harmful 
modes  of  dress  prevalent  among  them.  The  short  corset 
limits  respiratory  movements  and  tends  by  its  direct  com- 
pression to  force  several  of  the  viscera  inward  and  down- 
ward, and  both  this  and  the  modern  straight-front  corset  keep 
the  lower  thorax  and  entire  abdomen  of  the  wearer  in  splints, 
even  when  not  very  tightly  laced.  In  this  way  the  muscles 
of  the  underlying  region — precisely  those  whose  function  it  is 
to  help  support  the  organs  in  place — are  prevented  from  obtain- 
ing any  efficient  exercise,  so  that  increasing  flabbiness  and 
atrophy  of  the  abdominal  walls  ensue  as  a  matter  of  course. 

"  Further,  the  heavy  dragging  skirts,  unsupported  in  the 
case  of  most  fashionable  ladies  except  by  pressure  upon  the 
ever-weakening  trunk  muscles,  with  some  help  from  the  pro- 
jecting hips,  exert,  whenever  the  victim  is  on  her  feet,  a  con- 
tinual downward  traction  upon  both  the  relaxing  walls  and 
yielding  contents  of  the  abdomen. 

"  In  view  of  these  conditions  the  only  wonder  is  that  any 
woman  who  has  conformed  to  the  requirements  of  fashion 
during  the  years  of  adolescence  (when  the  structures  involved 
are  especially  pliant  and  easily  pressed  or  stretched  away  from 
the  normal),  is  to  be  found  with  healthful  abdominal  organs  in 
their  proper  positions.  And  since  many  more  young  men  than 
formerly,  especially  soldiers,  militiamen,  and  the  cadets  in  the 
numerous  military  schools,  have  taken  to  holding  up  their 
trousers    with    tightly    buckled    belts,    which    are    only    less 


462  THE    GASTRO-INTESTINAL    CLINIC 

injurious  than  corsets,  we  may  expect  to  meet  in  the  male  sex 
wjth  a  larger  crop  of  displaced  organs  by  and  by.     .     .     ." 

Abdominal  Displacements  as  Causes  of  Pelvic  Disease. — 
"  Since  writing  the  foregoing  part  of  this  article  I  have  read 
Dr.  W.  Gill  Wylie's  paper  on  Anaemia  as  Observed  in  a 
Gynecological  Clinic,  etc.,  which  appeared  in  the  Medical 
Record  of  May  20,  1899.  It  is  gratifying  that  this  most  distin- 
guished gynecologist  freely  admits  the  only  important  point 
I  have  made  here,  which  there  seemed  any  likelihood  of  being 
disputed — that  is,  that  ptosis  of  the  stomach  and  colon  is  a 
frequent  cause  of  uterine  displacements.  Referring  to  cases 
of  '  melancholia,  hysteria,  hypochondria,  etc.,'  he  says :  '  These 
cases  are  frequently  associated  with  relaxed  abdominal  organs 
when  there  are  loose  kidneys,  ptosis  of  stomach,  with  omentum 
and  intestines  crowding  down  in  the  pelvis  on  top  of  a  retro- 
verted  or  flexed  uterus,  and  the  patients  have  been  treated  in- 
definitely zvith  pessaries  for  falling  of  the  zvonib/  etc. 

"  In  the  same  paper  Wylie  also  discusses  cancers  and  ulcers 
of  the  stomach  and  intestines,  constipation,  chronic  appendi- 
citis, obstruction  of  the  gall-ducts,  chronic  colitis  and  proctitis, 
etc.,  as  causes  of  anaemia. 

A  Tribute  to  American  Surgery. — "  The  general  surgeons, 
also,  are  turning  to  the  digestive  organs  as  a  fruitful  field,  and 
are  already  pulling  up  and  stitching  in  place  prolapsed  stomachs 
and  taking  tucks  in  dilated  ones.  There  are,  indeed,  condi- 
tions in  which  these  new  operations  may  be  indicated.  .  .  . 
When  the  pylorus  is  obstructed  by  a  tumor,  the  cicatrix  of  a 
healed  ulcer,  or  other  cause  which  is  insuperable  by  milder 
measures,  or  in  persons  who  cannot  afford  either  the  time  or 
expense  of  prolonged  treatment  by  massage,  gymnastics  (or 
sometimes  a  period  of  rest  in  bed),  intragastric  electricity,  etc., 
required  to  effect  a  cure,  it  is  entirely  proper  to  invoke  the  aid 
of  the  surgeon.  Let  us,  also',  render  a  full  tribute  of  praise 
to  the  untiring  energy  and  genius  of  the  men  who  have 
wrought  such  marvelous  results  in  abdominal  surgery  in  these 
latter  days — especially  our  American  confreres^  who  now  stand 


SPLANCHNOPTOSIS  463 

unsurpassed  in  their  line.  But  at  the  same  time,  it  is  just  that 
the  equally  beneficent  and  often  life-saving  work  now  being 
done  in  this  region  by  less  dangerous,  even  if  less  rapid  and 
brilliant,  methods  should  be  given  its  proper  meed  of  recogni- 
tion. .  .  . 

"  Edebohls  puts  forward  the  claim,  supported  by  the  dictum 
of  Glenard,  that  though  there  may  be  cases  of  movable  kidney 
without  enteroptosis,  there  can  be  no  enteroptosis  without 
movable  kidney.  This  statement,  notwithstanding  the  high 
authority  from  which  it  emanates,  will  not  bear  the  test  of 
clinical  experience.  Most  of  the  special  workers  in  this  field 
see  cases  that  disprove  it.  My  own  records  alone  show  num- 
bers of  such.  Two  of  the  three  cases  reported  below  [in  the 
succeeding  lecture]  had  gastroptosis  without  nephroptosis." 

Of  course  it  is  manifest  that  when  the  liver  falls,  the  right 
kidney  must  be  carried  down  with  it,  but  a  gastroptosis  would 
not  seem  necessarily  to  involve  a  nephroptosis,  and  my  observa- 
tions show  that  the  latter  by  no  means  always  accompanies  it. 


LECTURE  XLIV 

DISPLACEMENTS,  ETC.,  OF  THE  ABDOM- 
liNAL  VISCERA,  CONCLUDED,  WITH  RE- 
PORTS OF  ILLUSTRATIVE  CASES 

To  this  subject  of  the  displacements,  dilatations,  etc.,  of  the 
abdominal  viscera  I  am  devoting  what  you  may  consider  a 
disproportionate  amount  of  space  and  time ;  but  they  are  among 
the  most  frequent,  as  well  as  among  the  more  serious,  of  the 
affections  of  the  gastro-intestinal  tract  and  at  the  same  time, 
though  very  easily  recognized  after  a  little  instruction  as  to  the 
proper  methods,  they  are,  even  at  this  beginning  of  the 
twentieth  centur}^,  perhaps  the  most  commonly  neglected  or 
overlooked  of  all  the  disorders  that  are  capable  of  causing  suf- 
fering and  shortening  life. 

In  the  same  paper  cited  in  the  preceding  lecture,  I  reported 
the  following  cases,  which  illustrate  various  phases  of  displace- 
ments and  dilatations  as  well  as  the  methods  of  treatment 
which  may  be  hopefully  employed  in  the  management  of  them : 

Reports  of  Cases  of  Displacements  of  Stomach,  Colon, 
etc. — "  Case  I. — A  married  lady,  aged  fifty-six,  consulted  me 
September  20,  1898.  Her  weight  then  was  ninety-two  pounds, 
and  she  had  been  in  ill  health  for  several  years,  complaining 
particularly  of  her  stomach.  She  had  had  the  best  of  medical 
advisers  before,  but  had  never  been  examined  by  a  stomach 
specialist,  and  the  only  diagnosis  reached,  so  far  as  she  knew, 
was  dyspepsia  and  nervous  prostration.  Her  worst  complaint 
was  a  '  sore,  tired,  distressed  feeling  in  the  pit  of  the  stomach 
and  a  constant  dragging  sensation  when  on  her  feet ' ;  also 
great  weakness,  a  poor  appetite,  and  constipation.  She  had 
passed  the  menopause  eight  years  before.     The  examination 

464 


DISPLACEMENTS    OF    THE    ABDOMINAL    VISCERA  465 

after  inflation  with  CO2  showed  a  marked  prolapse  of  the  entire 
stomach  with  dilatation,  the  lesser  curvature  being  just  below 
the  lowest  ribs,  and  the  greater  curvature  four  inches  below 
the  level  of  the  umbilicus.  The  liver  was  enlarged  decidedly, 
and  the  heart  was  somewhat  hypertrophied,  the  area  of  dullness 
extending  to  the  nipple  line  and  the  apex  beat  being  found  in 
the  same  line.  The  kidneys  were  in  normal  position,  as 
demonstrated  by  repeated  careful  examinations.  Transverse 
colon  pushed  downward  below  stomach.  Other  organs  nega- 
tive. Analysis  of  stomach  contents  showed  a  slight  excess  of 
HCl,  but  fortunately  not  enough  to  contra-indicate  abdominal 
massage.  The  treatment  consisted  of  a  bland  and  easily 
digestible  diet,  special  exercises  for  the  abdominal  muscles,  a 
special  abdominal  supporter  containing  springs  which  exerted 
strong  upward  pressure ;  full  massage,  including  deep  kneading 
of  the  abdominal  region ;  galvanism  from  spine  to  solar  plexus, 
and  also  over  the  course  of  the  pneumogastrics  in  the  neck. 
Her  skin  was  sallow,  almost  cachectic,  and  her  countenance 
showed  mental  depression.  The  urine  contained  an  excess  of 
indican.  She  received  in  the  way  of  medicine  strychnine  and 
hypophosphites  for  a  part  of  the  time,  and  a  mixture  of  nuclein 
and  bone-marrow  later.  The  Drysdale  aperient  was  given  for 
the  bowels.  This  was  a  very  exceptional  case,  in  that  the 
stomach  could  not  be  trained  to  tolerate  a  tube  or  even  the 
fine  rheophore  of  an  intragastric  electrode,  and  therefore  intra- 
gastric electricity,  one  of  the  most  efficient  remedies  at  our 
command,  could  not  be  given. 

"  October  6.,  Her  appetite  has  come  up,  and  the  dragging 
sensation  is  much  relieved. 

"  November  14.  Still  weak,  but  has  gained  five  pounds. 
Scarcely  any  discomfort  now.  Lower  border  of  the  stomach 
one  and  a  half  inches  below  the  umbilicus. 

"  November  21.  Stomach  extends  to  umbilicus  only.  Area 
of  liver  dullness  normal.  No  more  dragging  or  distress  in 
stomach.     Appetite  better. 

"  December  27.  Feels  much  stronger  and  better.  Can  walk 
eight  squares  now  without  getting  tired. 

"  Januar}^  24.  Still  improving;  stronger;  better  color,  and 
good  sleep. 

"  At  the  last  examination,  made  shortly  after  this,  her 
stomach  had  come  up  so  far  that  the  lower  border  was  entirely 
above  the  umbilicus.     She  had  not  fully  recovered  her  normal 


466  THE    GASTRO-INTESTINAL    CLINIC 

weight  and  color,  but  felt  so  well,  as  compared  with  her  former 
condition,  that  she  could  not  see  any  necessity  for  continuing 
treatment  longer. 

"  The  two  following  cases  exemplify  further  what  can  now 
be  accomplished  without  surgery.  My  records  contain  scores 
of  cases  of  Glenard's  disease  in  which  not  only  have  the 
symptoms  been  either  removed  or  markedly  ameliorated  with- 
out the  help  of  the  knife,  but  also  in  many  of  them  the  pro- 
lapsed stomachs  have  been  gradually  brought  up  to  nearly  their 
normal  positions  (as  in  Case  I.  above),  and  the  dilated  ones, 
when  not  due  to  obstruction,  have  almost  uniformly  been  con- 
tracted until  the  greater  curvature  has  been  brought  well  up 
above  the  level  of  the  umbilicus.  Occasionally  even  the  loose 
kidneys  have  ceased  to  be  movable  or  even  palpable,  and  when 
this  failed  to  be  accomplished  the  pain  and  tenderness  in  the 
affected  kidneys  in  nearly  all  the  cases  have  been  wholly 
relieved. 

Pronounced  Gastrectasis. — "  Case  II. — Unmarried  lady 
aged  twenty-three;  came  under  treatment  January  17,  1899. 
Always  well  until  the  previous  April,  when  she  had  scarlet 
fever,  and  following  that,  according  tO'  her  own  statement, 
albuminuria.  This  disappeared  two  weeks  ago.  For  half  a 
year  past  she  has  complained  very  much  of  morning  nausea, 
with  occasionally  nausea  all  day.  Menses  irregular  of  late  and 
very  painful.  Always  very  constipated;  often  several  days 
without  a  stool.  Does  not  take  laxatives  except  very  rarely. 
Much  flatulency,  the  gas  passing  freely  both  ways.  Used  'to 
ride  a  wheel,,  but  could  not  now,  being  too  weak.  She  was 
extremely  thin  in  flesh  and  very  anaemic.  Examination  showed 
liver  enlarged  slightly,  lungs  normal,  and  heart  enlarged  about 
one  inch  to  the  left ;  apex  beat  also  too  far  to  the  left.  Stomach 
dilated  from  normal  above  to  twO'  inches  below  the  level  of  the 
umbilicus.  Uterus  anteflexed  and  very  sensitive  to  the  touch. 
Left  ovary  also  sensitive,  though  not  appreciably  swollen. 
Much  leucorrhea.  Findings  otherwise  negative.  Analysis  of 
the  stomach  contents  after  Ewald  test  breakfast  showed  a  total 
acidity  of  40,  but  no  free  HCl  by  the  Mintz  method,  and  a  small 
amount  of  mucus.     The  urine  was  found  normal  by  repeated 


DISPLACEMENTS    OF    THE    ABDOMINAL   VISCERA  46/ 

examinations,  except  that  there  was  an  excess  of  triple  phos- 
phates. 

"  The  treatment  included  faradism  applied  directly  to  the 
inner  walls  of  the  stomach  by  means  of  my  improved  intra- 
gastric electrode,  massage,  special  exercises  for  the  abdominal 
muscles,  reform  dress,  and  tonic  medication,  including 
especially  HCl  and  pepsin;  also  a  careful,  but  regular  use  of 
mild  laxatives.  The  result  was  fortunate  in  spite  of  a  severe 
and  stubborn  attack  of  influenza  which  came  on  during  the 
treatment,  and  of  a  pending  marriage  engagement  with  its 
disturbing  influence.  She  was  well  enough  to  discontinue 
active  treatment  early  in  April,  and  my  last  entry  showed  the 
lower  boundary  of  her  stomach  to  be  one  and  a  half  inches 
above  the  umbilicus,  and  the  liver  and  heart  both  within  their 
normal  limits.  Her  bowels  were  regular  without  laxatives, 
and  all  nausea  had  disappeared. 

Dilated  Stomach,  Movable  Kidney,  etc. — "  Case  III. — Lady 
aged  thirty,  married  six  years  but  never  pregnant,  consulted 
me  September  14,  1898.  The  chief  complaint  for  which  she 
desired  relief  was  a  pain  alleged  to  be  in  the  region  of  the 
right  ovary,  and  for  which  she  had  received  treatment  per 
vaginam  off  and  on  for  five  years.  She  had  indigestion  after 
sweets  or  fried  things,  and  suffered  from  dizzy  spells.  She 
was  also  nervous,  often  constipated,  and  had  a  sallow  com- 
plexion. 

"  Examination  showed  nothing  abnormal  in  the  pelvis, 
except  that  the  uterus  was  inclined  slightly  backward.  No 
swelling  or  sensitive  spots  in  the  adnexa.  Liver,  heart,  and 
lungs  were  normal.  The  stomach  was  dilated  to  one  inch 
below  the  umbilicus,  and  a  light  non-nitrogenous  luncheon  was 
not  yet  out  of  it  at  the  end  of  three  hours,  showing  bad 
motility.  Splash  pronounced  even  before  drinking  anything. 
Right  kidney  quite  movable  and  also  tender.  The  appendix 
was  also  slightly  thickened  and  tender.  The  stomach  contents 
after  the  Ewald  test  breakfast  showed  no  free  HCl,  but  a  total 
acidity  of  38 ;  some  gastric  catarrh. 

"  Treatment :  abdominal  supporter,  faradism  with  my  intra- 
gastric electrode,  abdominal  exercises,  massage,  lavage,  laxa- 
tives, and  tonics,  including  HCl. 

"  Result :  December  23  she  reported  that  she  felt  as  well 
as  she  ever  did,  and  though  all  her  faulty  organs  were  not 
anatomically  correct,  she  could  not  afford  to  go  on  with  treat- 


468  THE    GASTRO-INTESTINAL    CLINIC 

ment.  Her  stomach  then  extended  to  one  inch  above  the  level 
of  the  umbilicus  instead  of  an  inch  belov^  as  at  first;  it  emptied 
itself  in  about  the  normal  time.  There  was  no  longer  com- 
plaint of  pain  in  the  region  of  either  the  appendix  or  the  right 
kidney,  which  was  still  somewhat  movable.  She  was  symp- 
tomatically  well,  and  her  gastric  dilatation  was  virtually  cured. 

Comparison  of  the  Results  from  Surgical  and  Mechanical 
Treatment. — "  Most  of  the  points  already  made  are  strikingly 
confirmed  in  a  recent  paper  by  Stengel  and  Beyea.^  They 
report  very  fully  a  case  occurring  in  the  practice  of  the  late 
Dr.  Wm.  Pepper,  which  was  carefully  studied  by  him  and  by 
Dr.  Sten.gel.  It  was  that  of  an  unmarried  woman  of  twenty- 
five  with  an  extreme  degree  of  splanchnoptosis,  the  stomach 
having  been  displaced  to  within  one  and  a  half  inches  oi  the 
pubes,  the  intestines  also  displaced  downward,  and  the  right 
kidney  dislocated  and  movable.  No  reference  was  made  to 
the  condition  of  the  pelvic  organs  or  appendix.  There  was  no 
history,  the  authors  say,  of  traumatism,  illness,  nor  of  abdom- 
inal distention  by  pregnancy  or  fluid  effusion,  to  explain  the 
displacement,  and  they  state  that  '  the  cause,  therefore,  must  be 
considered  as  most  probably  compression  of  the  thorax  by 
tight  clothing  and  relaxation  of  the  ligaments.' 

"  A  nephrorrhaphy  was  first  skillfully  done  by  a  prominent 
surgeon  and  was  without  marked  results,  though  usually  this 
operation  is  followed  by  relief  of  the  symptoms  due  to  the 
renal  mobility.  The  right  kidney  continued  to  be  palpable, 
below  its  proper  position,  and'  often  painful.  The  flatulency, 
constipation,  and  other  severe  gastro-intestinal  symptoms  per- 
sisted. The  extreme  gastroptosis  continued,  and  the  organ 
even  increased  in  size  after  the  nephrorrhaphy.  A  year  later, 
in  April,  1898,  Dr.  Beyea  did  an  ingenious  operation  to  bring 
up  and  hold  the  stomach  in  place.  Tucks  were  taken  in  the 
gastrophrenic  ligament  and  in  the  gastrohepatic  omentum. 
Nine  months  later  the  patient  was  found  to  have  gained  in 
health  and  weight,  .and  by  the  end  of  thirteen  months  she  was 
decidedly  better  in  all  ways.  Examination  showed  the  greater 
curvature  one  and  a  half  inches  below  the  level  of  the  um- 
bilicus. 

"  This  was  a  very  creditable  result  for  so  bad  a  case,  but  it  is 

'  Gastroptosis;  Report  of  a  Case  in  which  a  New  Operation  was  Undertaken 
an4  the  Patient  Greatly  Improved,  American  Journal  of  the  Medical  Sciences, 
June,  1899. 


DISPLACEMENTS    OF    THE    ABDOMINAL    VISCERA  469 

worthy  of  particular  notice  that  it  was  not  so  favorable  a 
result  as  was  obtained  in  my  Case  I.,  in  which  non-surgical 
methods  only  were  employed." 


Conclusions. — The  following  conclusions  drawn  from  the 
statistics  embodied  in  the  paper  and  from  the  foregoing  re- 
ports of  cases  seem  worthy  to  be  repeated  and  especially  em- 
phasized here : 

"  I.  The  fact  that  over  one-half  the  patients  examined  at 
my  offices  during  a  period  of  about  three  years  suffered  with 
displacement  or  dilatation  of  either  one  or  several  of  the 
abdominal  organs,  shows  the  enormous  frequency  of  these 
serious  diseased  conditions — a  state  of  affairs  little  understood 
or  appreciated  by  the  profession  at  large. 

"  2.  The  fact  that,  in  sO'  far  as  the  patients  or  their  friends 
were  aware,  not  more  than  one  per  cent,  of  the  large  number  of 
362  displacements  and  dilatations  of  abdominal  organs  had 
been  previously  diagnosticated,  indicates  an  extraordinary  in- 
difference to  this  important  class  of  cases  on  the  part  of  physi- 
cians generally. 

"3.  There  is  a  deplorable  lack  of  knowledge  of  what  can  be, 
and  is  being,  done  in  abdominal  displacements  and  dilatations 
by  simple,  safe,  and  efficient,  even  though  often  tedious,  non- 
operative  methods." 

In  summing  up  this  whole  subject  of  the  abdominal  displace- 
ments— splanchnoptosis — let  me  impress  upon  you  as  strongly 
as  possible,  both  for  the  prevention  and  cure  of  them  (in  so  far 
as  a  cure  is  possible),  the  importance  of  hygienic  living.  That 
is,  there  should  be  regular  and  systematic  exercise  of  the 
abdominal  muscles,  and  the  clothes  worn  should  always  admit 
of  such  exercise,  instead  of  being  virtual  abdominal  splints 
which,  by  preventing  any  proper  exercise  of  those  muscles, 
allow  them  to  become  weakened  and  relaxed  and  finally  atro- 
phied so  that  they  cannot  possibly  support  the  viscera.  Besides, 
you  should  use  your  utmost  endeavors  to  see  that  your  patients 
do  not  drag  down  their  abdominal  viscera  by  heavy  skirts  hung 


470  THE    GASTRO-INTESTINAL    CLINIC 

from  the  waist  instead  of  from  the  shoulder,  or  by  overloading 
their  stomachs  with  indigestible  food  in  amounts  twice  as 
great  as  their  activities  require. 

It  is  quite  possible  that  you  may  not  accomplish  much  at 
first  in  thus  stoutly  opposing  the  irrational  dictates  of  Fashion, 
but  you  will  have  at  least  performed  a  duty,  and  have  helped 
to  sow  seed  that  must  bear  fruit  by  and  by. 

Further  experience  has  confirmed  the  claim  that  the  hygienic 
and  mechanical  measures  described  in  the  preceding  lectures 
may  be  depended  upon  to  improve  nearly  all  cases  of  visceral 
displacements  and  to  cure  many  of  them.  But  it  should  be 
added  here  that  abdominal  surgery  in  the  best  hands  is  show- 
ing increasingly  good  results  in  the  same  class  of  derange- 
ments, and  is  therefore  to  be  hopefully  invoked  after  other 
means  have  failed  and  particularly  in  patients  who  cannot 
afford  the  time  and  money  required  to  carry  out  successfully 
the  mechanical  forms  of  treatment. 


I 


LECTURE  XLV 
ACUTE   AND    SUBACUTE    GASTRITIS 

Under  the  above  general  head  it  will  be  convenient,  and 
pathologically  as  accurate  as  our  present  knowledge  will  per- 
mit, to  group  the  following  affections  of  the  stomach:  i. 
Simple  acute  gastric  catarrh ;  2,  the  more  or  less  transient 
gastric  attacks  which,  though  usually  afebrile,  resemble  acute 
gastritis,  except  in  their  comparative  mildness,  often  called 
acute  indigestion  in  this  country  and  England,  and  denomi- 
nated by  the  French  emharass  gastrique,  while  the  Germans, 
according  to  Ewald,  call  the  same  condition  status  gastricus; 
and,  3,  the  other  fornis  of  gastric  inflammation  which  run  a 
short  course,  usually  to  their  termination  either  in  death  or 
recovery,  including  toxic,  phlegmonous,  sympathetic,  and  in- 
fectious and  parasitic  or  mycotic  gastritis.  The  more  chronic 
forms  of  gastritis,  including  the  ordinary  and  the  sthenic  or 
acid  type,  will  then  receive  separate  consideration  later. 

Pathology  of  the  Gastric  Inflammations. — From  analogy,  as 
well  as  from  actual  observation,  we  may  infer  that  pathologic 
alterations  similar  tO'  those  in  other  mucous  membranes  occur 
in  the  mucosa  of  the  stomach,  though  for  obvious  reasons  the 
lighter  forms  of  inflammation  cannot  be  sO'  satisfactorily 
studied  in  the  latter.  Generally  speaking,  inflammation  is  a 
progressive  process  expressive  of  a  reaction  of  the  tissues  to  an 
irritant  which  is  not  strong  enough  to  cause  death.  A  constant 
characteristic  of  inflammation  is  the  invasion  of  new  tissue 
elements — blood  and  lymph  cells,  wandering  connective  tissue 
cells,  etc.  The  elements  of  protection  and  repair  underlie  the 
inflammatory  process,  and  even  if  retrogressive  changes  take 
place,  as  suppuration  and  necrosis,  they  are  accompanied  by 


4/2  THE    GASTRO-INTESTINAL    CLINIC 

progressive  changes  in  the  tissues  immediately  surrounding  the 
degenerated  areas. 

^  Inasmuch  as  inflammation  is  invariably  the  result  of  irrita- 
tion, the  degrees  of  the  inflammatory  process  will  vary  with  the 
strength  and  nature  of  the  irritant.  The"  difference  between  a 
simple  slight  gastritis  which  can  hardly  be  distinguished  from 
a  simple  hyperemia  and  a  gastritis  resulting  in  destruction  of 
the  parts  involved,  is  only  one  of  degree  and  not  of  kind. 
Gastritis,  therefore,  is  a  collective  term  covering  such  processes 
as  simple  acute  and  chronic  gastritis,  phlegmonous  or  purulent 
gastritis,  toxic  gastritis,  and  other  inflammations  of  the  gas- 
tric mucosa. 

Simple  Acute  Gastritis. — This  is  a  common  affection,  espe- 
cially in  the  hot  season  of  the  year.  Its  most  frec[uent  cause 
being  spoiled  or  decomposed  food,  especially  animal  food,  it  is 
naturally  most  prevalent  when  the  weather  predisposes  most  to 
putrefactive  processes.  Those  who  suffer  from  it  are  probably 
in  the  main  persons  having  atonic  or  dilated  stomachs,  as  well 
as  those  whose  stomachs  are  either  in  a  condition  of  chronic 
catarrh  or  at  least  insufficiently  supplied  with  gastric  juice. 
But  even  a  perfectly  healthy  person,  one  whose  stomach  is 
sound  and  digestion  ordinarily  normal,  can,  doubtless,  be  at- 
tacked with  acute  gastritis  in  consecjuence  of  having  ingested 
food  in  which  decomposition  has  developed  a  sufficient  nurtiber 
of  pathogenic  bacteria  or  their  toxins.  Our  knowledge  of  the 
pathology  of  this  condition  is  imperfect  for  the  reason  that  it 
is  very  rarely  fatal,  and  even  when  a  patient  does  chance  to 
die  from  the  effects  of  it,  the  post-mortem  changes  are  so  rapid 
that  the  exact  alterations  in  the  mucosa  due  to  the  disease  can- 
not usually  be  determined.  The  inflammation,  however,  in- 
volves both  the  superficial  columnar  epithelium  and  the  glandu- 
lar parenchyma.  The  histologic  changes  are  out  of  proportion 
to  the  symptoms.  The  surface  of  the  mucous  membrane  is 
covered  by  a  tough,  glassy,  cloudy  mucus.  The  mucosa  is 
hypersemic  and  swollen,  the  hyperjemia  being,  as  a  rule,  limited 
to,  or  at  least  most  marked  in,  the  pyloric  region.     Ecchymotic 


ACUTE    AND    SUBACUTE    GASTRITIS  473 

spots  are  scattered  throughout  the  mucosa.  The  microscope 
reveals  destruction  of  the  superficial  epithelium  and  round-cell 
infiltration.    Degeneration  of  the  organic  cells  may  take  place. 

The  symptoms  of  simple  acute  gastritis  are,  doubtless,  famil- 
iar to  all  of  you.  They  are  severe  pain  in  the  region  of  the 
stomach,  coming  on  after  a  longer  or  shorter  stage  of  invasion, 
during  which  there  is  usually  much  nausea,  thirst,  headache,  a 
full,  distended  feeling  in  the  stomach,  and  generally  fever. 
With  increasing  pain  and  distress,  vomiting  develops,  and 
cjuantities  of  undigested,  sour,  fermenting,  and  very  often  very 
offensive  liquid  or  semi-solid  matter  are  brought  up,  with 
usually  a  temporary  relief  of  the  pain.  With  appropriate  treat- 
ment, including  especially  rest  of  the  whole  body  in  bed  and 
particularly  entire  rest  of  the  gastric  functions,  such  an  attack 
almost  invariably  ends  in  two,  three,  or  four  days,  so  far  as 
the  acute  symptoms  are  concerned.  Not,  infrequently,  how- 
ever, there  is  left  behind  a  milder  catarrhal  process  in  either 
the  stomach  or  bowels,  which  is  then  the  cause  of  a  persist- 
ently furred  tongue,  lack  of  appetite,  and  constipation  or  diar- 
rhea, or  at  least,  an  uncomfortable  sensation  in  the  colon,  which 
is  characteristic  of  a  moderate  catarrhal  inflammation  there. 

Acute  gastritis  may  occasionally  be  simulated  by  vomiting 
of  nervous  origin,  and  cases  of  the  latter  may  even  be  asso- 
ciated with  paroxysms  of  severe  gastric  pain — gastralgia. 

The  diagnosis  turns  mainly  on  the  presence  or  absence  of 
fever  as  well  as  of  tenderness  on  deep  palpation.  With  acute 
gastritis  there  is  usually  some  fever,  and  always  more  or  less 
marked  tenderness  on  deep  pressure  over  the  stomach,  though 
tenderness  may  exist  also  in  nervous  vomiting  because  of  dis- 
ease in  the  solar  plexus.  Then,  in  the  neurotic  cases,  the  vom- 
iting is  more  apt  to  be  intermittent,  as  well  as  less  responsive  to 
simple  treatment. 

It  is  noteworthy,  however,  that  in  most  of  these  so- 
called  nervous  affections  of  the  stomach,  a  thorough  examina- 
tion reveals  some  pathologic  condition  in  either  the  stomach 
or  intestines — chronic  catarrh  somewhere  in  the  alimentary 


474  THE    GASTRO-INTESTINAL    CLINIC 

tract,  displacement  or  dilatation  of  the  stomach,  or,  very  fre- 
quently, a  movable  kidney.  Occasionally  the  cause  is  a  latent 
gastric  ulcer  or  undemonstrable  carcinoma. 

Acute  febrile  catarrhs  of  the  stomach  are  less  frequently  seen 
in  adults  than  in  young  children,  and  in  the  latter  probably 
involve  also  usually  the  duodenum  at  least,  if  not  the  whole 
small  intestine.  Such  cases  cannot  always  be  distinguished 
from  beginning  meningitis,  typhoid  fever,  malaria,  or  other 
fevers  at  first,  though  by  a  careful  process  of  exclusion  the 
diagnosis  can  usually  be  made  within  a  short  time. 

The  Treatment  of  Acute  Gastritis  is  simple  enough  when 
you  can  control  the  patient  and  friends,  and  prevent  aggra- 
vation of  the  disease  as  a  result  of  putting  into  the  stomach 
irritating  foods,  drinks,  or  medicines. 

Three  harmful  things  are  often  done:  i.  The  patients  them- 
selves usually  insist  upon  drinking  large  draughts  of  water 
which  has  been  rendered  irritating  to  the  inflamed  mucous 
membrane  by  the  addition  of  ice  or  lemon  juice,  or  some  other 
sharp  acid. 

2.  The  friends  are  apt  to  insist  upon  the  patient's  taking 
food,  in  spite  of  his  positive  repugnance  to  it,  and  notwith- 
standing the  fact  that  it  is  rarely  ever  retained. 

3.  The  attending  physician,  if  taught,  as  many  of  us  were, 
that  the  chief  remedy  for  vomiting  is  bismuth,  too  often  stuffs 
frequent  full  doses  of  that  or  some  other  equally  useless  and 
disturbing  drug  into  the  protesting  stomach. 

Bismuth,  in  such  acute  conditions,  is  usually  useless  and 
disturbing,  because  the  whole  system  is  suffering  from  a  tox- 
aemia which  calls  loudly  for  elimination  and  a  free  action  of  all 
the  emunctories,  including  especially  the  liver  and  the  intestines, 
while  this  drug  inhibits  somewhat  the  action  of  both,  valuable 
as  it  is  in  purely  local  inflammatory  lesions  of  the  stomach, 
as  in  gastric  ulcer,  etc.  I  well  remember  my  first  case  of  acute 
gastritis,  which  occurred  shortly  after  I  had  begun  practice  in 
'Atlantic  City.  The  patient  was  an  elderly  lady  with  doubtless  a 
dilated  stomach   (though  I  could  not  have  determined  then 


ACUTE    AND    SUBACUTE    GASTRITIS  475 

whether  it  was  within  normal  Hmits  or  filled  the  whole  abdom- 
inal cavity),  and  she  had  been  eating  excessively  of  various  rich 
viands,  including  oysters  out  of  season.  I  promptly  prescribed 
bismuth  in  lo-grain  doses,  which  were  rejected  as  soon  as 
swallowed,  as  was  also  water  and  everything  else  that  she 
took.  During  my  absence,  some  other  old  lady  put  on  a  mus- 
tard plaster,  which  immediately  gave  relief,  and,  with  entire 
abstinence  from  food,  recovery  was  thereafter  rapid. 

The  chief  indications  to  be  met  by  treatment  are  ( i )  rest 
of  the  inflamed  organ,  and  (2)  elimination,  that  is,  removal  of 
any  remaining  particles  of  fermenting  or  putrefying  food,  as 
well  as  of  the  previously  formed  toxins. 

As  digestion  will  have  been  completely  arrested,  you  will, 
of  course,  withhold  all  food  for  twelve  to  twenty-four  hours  at 
least,  or  even  till  the  acute  stage  is  over,  especially  in  adults; 
and  as  you  are  dealing  with  a  highly  inflamed  membrane,  you 
will  avoid  making  matters  worse  by  administering  any  reme- 
dies that,  by  reason  of  their  taste,  smell,  or  other  mechanical 
properties,  could  either  further  irritate  that  membrane  or  ex- 
cite reflexly  the  vomiting  center.  And  unless  the  pain  is  so 
violent  as  to  make  the  duty  of  instantly  relieving  it  outweigh 
all  other  considerations,  you  will  not  lock  in  the  toxic  products 
by  giving  opiates. 

Besides  observing  the  foregoing  cautions  as  to  what  not  to 
do  or  permit  to  be  done,  you  may  usually  shorten  somewhat  the 
period  of  cure  and  often  at  the  same  time  lessen  the  discomfort 
of  the  patient,  by  a  few  simple  remedial  measures.  Consider- 
able alleviation  often  results  from  a  wet  pack  or  compress 
applied  directly  over  the  stomach,  the  moisture  to  be  well 
confined  by  an  oiled  silk  or  some  other  impervious  cover,  and 
the  whole  held  firmly  against  the  body  by  a  flannel  binder. 
This  is  usually  applied  cold,  but  when  there  is  a  violent,  colicky 
pain,  it  is  better  to  have  it  as  hot  as  possible,  and  even  to 
increase  its  counter-irritant  properties  by  sprinkling  turpen- 
tine on  it. 

For  the  purpose  of  more  thoroughly  emptying  the  stomach 


4/6  THE    GASTRO-INTESTINAL    CLINIC 

than  nature  can  accomplish  unaided,  emetics  have  been  sug- 
gested, but  are  decidedly  contra-indicated,  and  the  tube  which 
has'been  recommended  by  some  authorities  is  better  avoided  in 
these  acute  cases,  except  as  a  last  resort,  though  often  indispen- 
sable in  chronic  gastric  catarrh.  The  best  method  is  to  have 
the  patient,  when  an  adult,  drink  very  freely  of  warm  or  tepid 
water — not  less  than  a  pint  at  a  time — which,  being  promptly 
vomited,  will  usually  empty  finally  every  corner  or  pocket  of 
the  stomach.  Let  this  be  taken  several  times,  at  intervals  of 
ten  or  fifteen  minutes,  after  which  marked  relief  of  all  symp- 
toms nearly  always  follows.  Having  thus  thoroughly  evacu- 
ated and  cleansed  the  stomach,  you  should  limit  fluids  by  the 
mouth  to  not  more  than  half-ounce  drinks  (or,  in  babies,  at 
first  teaspoonful  doses)  of  plain,  moderately  cooled  water — 
not  ice-cold,  as  a  rule.  Sometimes,  however,  in  these  small 
quantities,  even  iced  water  agrees  well.  Small  pieces  of  ice, 
swallowed  at  intervals,  suit  better  than  water,  and  in  severe 
adynamic  cases  they  can  often  be  administered  with  advantage 
in  teaspoonful  or  tablespoonful  doses  of  a  dry  champagne  at 
half-hour  intervals. 

Medicinal  Remedies. — When  medicines  are  necessary,  the 
most  useful  one  at  this  stage  I  have  always  found  to  be  calomel 
in  doses  of  one-sixth  grain  for  adults,  or  one-twelfth  grain  for 
infants,  taken  dry  on  the  tongue,  zvithout  more  than  one  grain 
of  sugar  of  milk  as  a  diluent,  and  zvithout  any  fliiid  to  zuash  it 
dozvn.  Repeat  the  dose  in  bad  cases  every  half-hour  till  it  pro- 
duces copious  yellow  stools.  When  administered  strictly  as 
above  directed,  it  is  almost  never  vomited,  and  the  efifect  is 
nearly  always  most  happy. 

Another  remedy  of  approved  value  is  arsenite  of  copper,  but 
it  must  be  given  in  very  minute  doses  in  order  not  to  disagree. 
You  may  dissolve  one  of  the  ^-rn-grain  tablets  in  five  or  six 
teaspoon fuls  of  water,  and,  wdien  the  symptoms  are  very  ob- 
stinate, administer  a  teaspoonful  every  half-hour,  in  alterna- 
tion with  the  calomel  powders.     (See  Lecture  XXXIV.) 

Both  the  calomel  and  cuprum  arsenite  are  equally  helpful 


ACUTE    AND    SUBACUTE    GASTRITIS  477 

when  the  gastritis  is  compHcated  by  diarrhea,  with  thin,  watery 
or  offensiv2  stools.  In  that  case  the  calomel  will  need  to  be 
stopped  as  soon  as  the  change  in  the  character  of  the  stools 
shows  its  action. 

When  violent  pain  persists  after  the  stomach  has  been  com- 
pletel}^  emptied,  it  means,  usnally,  that  a  portion  of  the  fer- 
menting gastric  contents  has  passed  into  the  intestines  and 
affected  that  region.  The  action  of  the  calomel  may,  in  such 
cases,  ha\e  to  be  supplemented  by  copious  enemas,  to  which 
sulphate  of  magnesia,  or  even  castor  oil  and  turpentine,  may 
be  added,  if  necessary.  These  enemas  are  also  desirable  in  the 
cases  marked  by  obstinate  constipation,  which  the  calomel 
alone  does  not  speedily  overcome. 

When  the  acute  stage  is  over,  bismuth  often  proves  the  best 
remedy  for  the  subacute  catarrhal  condition  which  tends  to 
linger  and  become  chronic  in  some  cases.  It  needs  to  be  borne 
in  mind  that  an  often  unrecognized  chronic  gastritis  is  one  of 
the  most  frequent  predisposing  causes  of  acute  attacks.  After 
evacuating  the  bowels  thoroughly,  it  may  be  necessary  to  resort 
to  rectal  alimentation  in  stubborn  cases,  especiallv  when  the 
patients  are  weak.  As  the  attack  subsides,  feeding  by  the 
mouth  should  be  begun  again,  and  cautiously  increased. 
Among  the  first  things  to  agree  will  probably  be  clam  broth, 
peptonized  milk,  whey  or  fresh  milk  prepared  with  Eskay's 
Food.  This  last  is  a  very  valuable  addition  to  our  stock  of 
suitable  preparations  in  case  of  debilitated  or  irritable  stom- 
achs, whether  in  adults  or  children.  Bovinine,  Plasmon, 
Mosquera's  Beef  Meal,  and  other  beef  powders  are  also  suit- 
able for  addition  to  milk  or  broths.  Full  feeding  must  then  be 
very  gradually  resumed.  See  Lecture  XX.  for  detailed  dietetic 
suggestions  and  lists  of  foods  from  which  you  may  select  dur- 
ing the  convalescence  from  various  gastro-intestinal  affections. 

Subacute  Gastritis — The  affection  which  we  call  acute  in- 
digestion and  the  French  cinbavras  gastrique,  does  not,  except 
by  its  comparative  mildness,  differ  greatly  in  its  aetiology, 
symptoms,  or  therapeutic  recjuirements  from  acute  gastritis,  and 


478  THE   GASTRO-INTESTINAL    CLINIC 

it  is  a  fair  inference,  that  it  does  not  differ  essentially  from 
it  pathologically.  As  already  stated,  I  do  not  believe  there 
can  be  a  marked  functional  disturbance  without  some  ana- 
tomic basis  for  it,  however  slight  or  transient.  Possibly 
the  attacks  of  acute  indigestion  which  fall  short  of  the 
severity  which  would  entitle  them  to  be  classed  under  acute 
gastritis,  have  no  greater  pathologic  basis  than  a  hypergemia, 
but  I  suspect  that  many  of  them,  if  the  mucosa  could  be  exam- 
ined at  their  height,  would  show  a  subacute  inflammatory 
process.  At  least  it  seems  logical  to  assume  this ;  but  proof  is 
lacking,  since  persons  do  not  die  of  such  attacks.  The  treat- 
ment should  be  practically  the  same  as  for  acute  gastritis — 
evacuation  of  the  stomach  and  calomel  first,  and  bismuth  with 
stomachics  later.  As  in  the  severer  form,  too,  abstinence  from 
all  food  and  hot  applications  or  counter-irritants  over  the  epi- 
gastrium are  very  useful  in  the  beginning,  and  drinking  hot 
water  proves  helpful  whether  it  provokes  emesis  and  thus  gets 
rid  of  the  irritant,  or  only  dilutes  the  latter. 


LECTURE   XLVI 

ACUTE  AND  SUBACUTE  GASTRITIS,  CON- 
CLUDED— SYMPATHETIC,  TOXIC,  PHLEG- 
MONOUS, AND  INFECTIOUS  AND  PARA- 
SITIC GASTRITIS 

Sympathetic  Gastritis. — Ewald  describes  separately  gas- 
tritis sympathetica,  which  is  the  form  of  the  disease  encoun- 
tered in  the  exanthems  and  the  infectious  fevers  as  typhoid, 
malarial  fever,  etc.  It  is  well  known  that  in  many  of  the 
graver  cases  of  fever  there  is  an  associated  gastritis,  and 
Ewald  considers  this  to  be  a  result,  in  such  cases,  of  a  reflex 
nervous  action.  The  pathology  of  these  cases  is  not  different 
in  all  probability  from  that  of  simple  acute  gastritis.  The 
symptoms  are  often  masked  and  the  treatment,  when  any  other 
than  that  required  for  the  primary  affection  is  practicable, 
should  follow  the  same  lines  as  in  the  simple  acute  form. 

Toxic  Gastritis  is  next  in  frequency  and  importance  to  the 
forms  already  described.  In  fact  all  the  varieties  of  gastritis 
are  of  either  toxic  or  bacterial  origin  and,  therefore,  the  term 
toxic  gastritis  does  not  entirely  differentiate  the  affection  under 
consideration.  It  is  that  form  of  inflammation  of  the  gastric 
mucosa  due  to  the  action  of  powerful  poisons  introduced  from 
without,  especially  the  caustic  acids  and  alkalies,  many  of  the 
metals  as  arsenic,  phosphorus,  etc.,  and  other  irritant  drugs. 
Such  substances  are  often  swallowed  either  accidentally  or 
purposely  with  suicidal  intent,  and  the  result  is  likely  to  be 
very  serious,  death,  in  the  case  of  the  more  caustic  substances, 
frequently  being  caused  by  a  perforative  peritonitis,  and  when 
this  is  prevented,  destructive  inflammation  may  be  set  up, 
especially  if  the  poison  is  swallowed  in  a  concentrated  form 

479 


480  THE   GASTRO-INTESTINAL    CLINIC 

and  at  a  time  when  the  stomach  is  empty.  The  more  diluted 
the  chemical  taken  and  the  greater  the  amount  of  gastric  con- 
tends to  which  it  is  added,  the  less  sudden  and  violent  naturally 
the  effect.  The  metal  poisons  produce  generally  a  less  violent 
gastritis,  though  when  taken  in  large  enough  amounts,  death 
results  quite  as  certainly  from  their  absorption  into  the  system. 

The  pathology  depends  first  of  all  upon  whether  an  actual 
caustic  substance,  or  some  other  irritant  poison  of  non-cor- 
rosive effect  has  been  taken.  The  pathologic  conditions  vary 
also  with  the  amount  and  concentration  of  the  poisons  ingested. 
There  may  be  only  a  slight  superficial  inflammation  or  the 
entire  mucosa  may  be  destroyed.  The  general  effect  of  the 
corrosive  poisons  is  the  production  of  eschars,  which  may  be 
tough  or  friable,  or  loose  in  texture.  These  eschars  vary  in 
color  with  the  different  chemicals.  They  may  be  brown  or 
black  from  the  disintegrated  blood  or  after  the  ingestion  of 
sulphuric  acid ;  orange-yellow  from  the  ingestion  of  nitric  acid ; 
white  or  grayish  from  oxalic  acid ;  white  or  gray  from  carbolic 
acid  or  mercury.'  Severe  hemorrhages,  ulcerations,  and  per- 
forations may  be  the  results  of  such  poisoning.  The  mineral 
poisons  in  large  doses  produce  mucoid  and  fatty  degeneration 
of  the  epithelial  cells  and  a  whitish  or  yellowish  appearance  of 
the  mucosa.  Other  poisons  in  dilute  form  may  cause  appear- 
ances not  unlike  those  present  in  simple  acute  gastritis. 

The  syinptoins  of  toxic  gastritis  are  a  severe  burning  pain 
and  vomiting  which  is  especially  characterized  by  the  fact  that, 
unlike  vomiting  in  most  other  cases,  it  increases  the  pain. 
There  are  also  seen  extreme  thirst,  fever,  prostration,  and  when 
perforation  with  peritonitis  results  there  will  be  collapse  and 
the  other  usual  phenomena  of  that  serious  condition. 

The  diagnosis  turns  mainly  upon  the  history,  and  when  some 
caustic  or  violently  irritant  chemical  has  been  swallowed,  you 
will  find  a  blistered  or  eroded  condition  of  the  mouth  and 
throat.  In  all  these  cases,  too,  there  is  an  exceptionally  rapid 
development  of  the  symptoms ;  but  tO'  differentiate  between 
some  of  the  forms  of  metal  poisoning,   as   from  arsenic  or 


ACUTE   AND    SUBACUTE    GASTRITIS  48 1 

antimony  on  the  one  hand,  and  some  of  the  forms  of  ptomain 
poisoning  on  the  other,  is  by  no  means  easy ;  in  the  latter  there 
is  a  more  intense  prostration  and  also  dilatation  of  the  pupils. 

The  treatment  of  toxic  gastritis  demands  a  prompt  evacua- 
tion of  the  stomach  whenever  possible,  and  tO'  wait  for  the 
administration  of  an  emetic  means  usually  the  loss  of  precious 
time.  In  this  form  of  gastritis  there  is  an  even  greater  neces- 
sity for  emptying  the  stomach  immediately  and  thoroughly 
than  in  the  simple  acute,  and  you  should  not  hesitate  to  wash 
it  out  with  the  help  of  the  tube,  when  it  is  possible  to  introduce 
it,  except  when  a  caustic  subtance  has  been  taken.  The  next 
step  must  be  to  administer  the  appropriate  antidotes,  both 
chemic  and  physiologic,  and  after  that  to  treat  the  corroded 
membranes  locally  by  mixtures  of  bismuth  and  limewater  or 
other  emollient  and  healing  remedies. 

In  alcoholic  gastritis,  which  may  be  considered  a  subvariety 
of  the  toxic  form,  the  treatment  may  be  much  the  same  as  in 
simple  gastritis,  except  that  considerable  stimulation  and  an 
earlier  resumption  of  feeding  will  be  necessary.  Beef  extracts, 
raw  eggs,  and  other  strongly  concentrated  nutriments  will  be 
in  order,  though  the  milk  preparations  advised  for  the  ordinary 
type  will  also  be  appropriate.  Bismuth  and  limewater  often 
prove  curative  in  this  form  after  the  extreme  irritability  of  the 
first  stage  has  been  measurably  abated.  Drop  doses  of  Fowler's 
solution  have  been  lauded  in  this  affection,  but  the  minute 
doses  of  cuprum  arsenite  already  mentioned  have  helped  more 
in  my  hands.  These  are  cases  in  which  the  sufferers,  on 
account  of  the  unquenchable  thirst,  are  most  inclined  to  go  on 
drinking  large  amounts  of  iced  water  or  other  drinks,  in  spite 
of  the  fact  that  they  are  immediately  vomited.  I  have  often 
seen  a  slop  jar  filled  with  gallons  of  fluid  which  has,  within  a 
few  hours,  been  poured  down  by  such  a  patient,  only  to  return 
instantly,  with  the  result  of  increasing  the  irritability.  In 
addition  to  carefully  regulated  doses  of  stimulants,  general 
nerve  sedatives  are  usually  indispensable  in  such  an  aggravated 
condition. 


482  THE    GASTRO-INTESTINAL    CLINIC 

Phlegmonous  or  Purulent  Gastritis. — This  is  at  the  same 
time  one  of  the  most  dangerous  and  one  of  the  rarest  diseases 
of  the  stomach.  Ewald,  when  he  wrote  the  first  edition  of  his 
book,  on  "  Diseases  of  the  Stomach,"  had  seen  only  one  case  of 
it  and  this  in  hospital.  It  is  situated  in  the  submucous  and 
muscular  layers  and  is  nearly  always  acute.  It  occurs  mostly 
in  men  and  is  most  frequent  in  the  active  period  of  adult  life — 
from  twenty  to  sixty  years  of  age.  Ewald  considers  the 
disease  to  be  due  to  bacterial  invasion.  It  may  result  from 
the  extension  of  a  perigastric  abs.cess  or  as  a  metastasis  from 
various  acute  infectious  diseases,  especially  pyemia,  puer- 
peral fever,  etc.,  and  it  may  be  either  diffused  or  circum- 
scribed. 

The  pathology  of  this  variety  of  gastritis  calls  for  no  ex- 
tended statement.  The  abscesses  may  be  very  small — pea  or 
hazelnut  size — or  very  much  larger. 

The  inflammation,  having  begun  in  the  submucous  connect- 
ive tissue,  extends  thence  to  the  mucosa.  The  pyloric  portion 
is  generally  invaded  more  than  the  other  regions  of  the 
stomach.  The  submucosa  is  swollen,  oedematous,  purulent,  or 
infiltrated  with  blood.  The  process,  extending  to  the  mucosa, 
produces  minute  perforations  in  the  latter,  imparting  to  it  the 
appearance  of  a  sieve.  Through  these  perforations  pus 
exudes.  The  muscularis  mucosa  is  also  involved,  showing 
infiltration  with  pus  cells  and  proliferation  of  nuclei.  The 
involvement  of  the  peritoneal  layer  may  lead  to  perforation. 

The  syinptonis  of  gastric  phlegmon  are  more  intense  than 
those  in  any  other  variety  of  gastritis  and  include  fever  which 
may  be  very  high, — even  105°  F., — violent  pain  coming  on  gen- 
erally rather  suddenly,  though  sometimes  preceded  by  vague 
symptoms,  great  thirst,  and  a  general  feeling  of  serious  illness. 
There  is  nearly  always  vomiting,  which  brings  up  mucus  and 
biliary  matter  with  sometimes  much  pus ;  also  either  constipa- 
tion or  diarrhea.  Extreme  restlessness,  jactitation,  and 
delirium  are  other  striking  symptoms.  The  prostration  is 
marked  and  death  is  likely  to  occur  in  coma. 


ACUTE    AND    SUBACUTE    GASTRITIS  483 

The  diagnosis  is  difficult,  if  not  impossible,  during  life. 
Both  Leube  and  Ewald  have  put  on  record  their  belief  that  it 
cannot  be  certainly  diagnosticated.  But  the  suddenness  of  the 
onset  and  extreme  violence  of  the  pain,  vomiting,  and  other 
symptoms,  with  increased  resistance  over  the  stomach, 
should  always  suggest  to  you  the  possibility  of  the  existence 
of  this  disease. 

The  treatment  is  extremely  unpromising,  and  unless  the 
diagnosis  can  be  made  in  time  to  admit  of  su-rgical  interven- 
tion, nothing  can  be  done  in  most  cases  except  to  allay  the 
pain  by  icebags  and  morphine  hypodermically  and  powerful 
stimulation  to  counteract  collapse. 

Infectious  and  Parasitic  Gastritis ^Every  gastric  inflam- 
mation must  be  accompanied  by  more  or  less  infection,  but 
numerous  authors  hold  that  in  certain  cases  of  acute  gastritis 
which  run  a  more  severe  and  protracted  course  than  usual,  a 
bacterial  infection  is  the  direct  exciting  cause.  In  another 
class  of  gastric  inflammations  closely  related  to  these,  the 
mucosa,  presumably  weakened  so  that  its  resisting  power  is 
lessened,  is  invaded  by  pathogenic  fungi  and  other  larger 
parasites  which  produce  a  form  of  gastritis. 

When  the  invading  organisms  are  fungi,  the  term  mycotic 
gastritis  is  appropriately  used  to  describe  the  resulting  affec- 
tion. The  gastric  mucosa  may  be  invaded  by  diphtheria 
bacilli,  giving  rise  to  a  pseudo-membranous  inflammation,  or, 
in  rare  cases,  the  anthrax  bacillus  may  invade  the  mucosa, 
giving  rise  to  inflammation  and  necrosis.  A  fibrinous  gas- 
tritis may  be  caused  by  the  favus  fungus  and  may  accompany 
pyemia,  septicemia,  puerperal  fever,  scarlet  fever,  smallpox, 
typhus,  etc.  Thrush  fungus,  the  yeast  fungus,  and  animal 
parasites  may  give  rise  to  inflammation  and  ulceration  of  the 
gastric  mucosa. 

Considerable    literature    has    accumulated    regarding    these 

forms  of  gastritis,  but  the  views  concerning  them   are  still 

largely  theoretical.     Infectious  gastritis  is  not  generally  re- 

■  garded  as  entitled  to  be  considered  in  a  separate  class  and 


484 


THE    GASTRO-INTESTINAL    CLINIC 


neither  it  nor  the  mycotic  form  has  such  well-defined  dis- 
tinguishing symptoms  that  it  can  be  certainly  diagnosticated 
from  the  other  varieties.  The  treatment,  supposing  the 
diagnosis  to  have  been  made,  must  be  practically  the  same  as 
for  simple  acute  gastritis. 


LECTURE  XLVII 

CHRONIC  ASTHENIC  GASTRITIS  (CHRONIC 
GASTRIC  CATARRH) 

Without  attempting  to  go  deeply  into  the  mooted  questions 
relative  to  the  exact  histology  of  the  different  forms  of  chronic 
inflammation  of  the  gastric  mucosa  and  its  glands,  I  shall  dis- 
cuss here  as  plainly  as  possible  the  more  practically  im- 
portant aspects  of  the  subject. 

Different  Forms  of  Chronic  Gastritis. — The  former  view 
that  chronic  gastritis  is  a  simple  inflammatory  process  involv- 
ing always  a  decrease  of  the  HCl  and  ferments,  along  with  an 
increased  secretion  of  mucus,  has  had  to  be  abandoned,  though 
it  dies  hard.  Boas,  Riegel,  Einhorn,  Hemmeter,  Van  Valzah 
and  Nisbet,  and  others  have  established  beyond  question  the 
fact  confirmed  by  hundreds  of  other  observers  that  cases  of 
chronic  gastritis  constantly  occur  in  which  there  is  either  a 
normal  or  excessive  secretion  of  HCl  and  the  ferments.  Boas 
calls  these  gastritis  acida  or  acid  gastric  catarrh.  A  further 
study  of  gastritis  has  revealed  the  fact  that  while  in  the  same 
stomach  the  mucosa  in  different  parts  may  sometimes  excep- 
tionally show  different  conditions,  the  secreting  cells  in  one 
place  undergoing  a  degenerative  process  and  in  another  a 
proliferative  one  at  the  same  time  or  at  different  times,  there 
is  usually  a  predominance  of  glandular  hyperplasia  in  the 
cases  characterized  by  excessive  secretion,  and  a  preponderance 
of  degenerative  processes  in  the  glands  of  those  showing  a 
deficiency  of  secretion. 

If  one  were  to  construct  a  pathology  of  chronic  gastritis  by 
a  process  of  reasoning  a  priori  instead  of  by  observations  at 
the  bedside  or  in  the  consultation  room  or  laboratory,  one 

485 


486 


THE    GASTRO-INTESTINAL    CLINIC 


would  be  led  very  naturally  to  the  view  that  in  every  such 
inflammation  there  must  be  at  first  full  or  excessive  functional 
activity  and  later  a  gradual  degeneration  or  atrophy  of  the 
secreting  cells,  with  finally  an  absence  of  secretion.  But  the 
physician  who  not  only  studies  his  cases  from  the  clinical  side 
symptomatically,  but  also  determines  the  proportion  of  HCl, 
etc.,  in  the  gastric  contents  of  each  dyspeptic  patient,  besides 
examining  microscopically  fragments  from  the  wash  water, 
does  not  have  to  examine  in  this  way  many  hundreds  of  cases 
before  he  finds  convincing  evidence  that  the  facts  are  quite 
different — that  while  some  comparatively  young  persons  suf- 
fering with  chronic  gastritis  will  show  a  persistent  absence  or 
low  percentage  of  HCl  (chronic  gastritis  anacida),  numerous 
patients  who  are  even  up  in  the  seventies  will  present  the  very 
opposite  condition,  /.  e.,  a  form  of  chronic  gastritis  with  a  con- 
stantly excessive  secretion  of  the  gastric  juice;  and  fragments 
of  mucosa  may  be  obtained  from  the  wash  water  in  the  one 
case  which  will  reveal  many  proliferating  glandular  cell  ele- 
ments, while  from  the  other  may  often  be  secured  evidences  of 
a  predominating  glandular  degeneration. 

Besides  these  two  widely  different  types  of  chronic  gastritis, 
which  not  all  authors  yet  recognize,  the  disease  is  also  divided 
into  a  primary  and  secondary  form,  secondary  gastritis  being 
in  the  nature  of  a  complication  of  various  other  diseases,  as 
tuberculosis,  nephritis,  hearf  disease,  hepatic  affections,  gastric 
carcinoma,  etc.  Mucous  gastritis  is  another  variety  which 
many  authors  consider  entitled  to  separate  consideration,  and 
the  asthenic  form  with  deficient  secretion  tends  to  develop  ulti- 
mately into  what  some  authors  class  as  a  separate  form — 
i.  e.,  chronic  atrophic  gastritis,  in  which  all  the  elements  of  the 
gastric  juice  are  wanting. 

Still  another  type  has  been  called  chronic  hypertrophic  gas- 
tritis, in  which  the  connective  tissue  proliferates  markedly  and 
the  glandular  structures  are  atrophied  by  compression.  This 
process  causes  much  thickening  of  the  gastric  walls  with 
usuallv  contraction  of  the  viscus  when  it  is  general,  but  en- 


CHRONIC    ASTHENIC    GASTRITIS 


487 


largement  with  finally  dilatation  when  the  connective  tissue 
of  the  pyloric  part  is  mainly  involved.  In  the  latter  cases 
the  pylorus  undergoes  hypertrophy  and  obstruction  of  the  out- 


FiG.  65. — Mucoid  and  cystic  degeneration  of  the  gastric  mucous  membrane 
in  a  case  of  chronic  tuberculosis,  X  25.  a,  small  cyst,  not  lined  with 
epithelium;  b^  blood-vessels;  c,  gastric  gland  opening  on  the  surface; 
d,  medium-sized  cysts,  for  the  most  part  lined  with  epithelium,  chiefly 
composed  of  goblet  cells.  At  the  surface  of  the  mucous  membrane  there 
is  a  great  increase  of  the  interstitial  tissue.     (R.  Langerhans.) 

let  results.    These  have  been  classed  by  some  writers  under  the 
head  of  chronic  stenosing  gastritis. 

While  in  its  severe  typical  form  chronic  asthenic  gastritis 
(ordinary  chronic  gastric  catarrh)  does  not  seem  to  be  as 
prevalent  in  this  country  as  in  Europe,  for  the  reason  probably 
that  there  is  a  less  widespread  abuse  of  alcoholic  liquors  and 


488  THE    GASTRO-INTESTINAL    CLINIC 

tobacco  here,  mild  forms  of  the  affection  are  common  enough 
and  often  pass  unrecognized.  It  is  very  frequently  treated  as 
ner^^ous  dyspepsia  with  drugs  or  rest  cures,  and  sometimes  by 
external  hydrotherapeutic  measures  mainly,  until  finally,  when 
the  intestines  have  become  involved  in  the  catarrhal  process, 
and  serious  impairment  of  the  general  nutrition  has  resulted, 
special  advice  and  treatment  are  sought. 

The  Pathology  of  Chronic  Gastritis  in  General. — There  is 
a  general  manifestation  of  long-continued  irritation  which  is 
common  to  all  chronic  inflammation  of  mucous  membranes. 
As  a  rule  it  brings  about  proliferation  of  connective  tissue  and 
destruction  of  the  more  highly  organized  parenchymatous 
tissue.  The  destruction  of  the  latter  takes  place  either  by  the 
direct  action  of  the  irritant  on  the  parenchymatous  cells,  or  by 
reason  of  the  encroachment  of  the  proliferating  connective 
tissue.  It  is  in  this  manner  that  cirrhosis  of  the  liver,  inter- 
stitial nephritis,  fibroid  phthisis,  etc.,  occur.  In  chronic  gas- 
tritis of  the  ordinary  asthenic  type  the  same  general  phe- 
nomenon is  observed,  though  with  many  variations  as  above 
explained.  The  glandular  elements  become  degenerated, 
while  the  connective  tissue  is  proliferated.  The  pathologic 
changes  vary  with  the  duration  of  the  disease  and  are  present 
not  only  in  the  mucosa,  but  in  the  deeper  layers  of  the  gastric 
wall. 

In  the  early  stages  the  mucosa  is  oedematous,  wrinkled, 
loose,  and  more  or  less  reddened.  Hemorrhage  or  ulceration 
may  occur.  The  mucous  membrane  is  covered  with  a  dull  gray 
mucus  containing  epithelial  and  pus  cells.  Later  the  epithe- 
lium and  the  glands  become  degenerated,  and  infiltration  of  the 
gastric  wall  with  hanphoid  cells  and  hyperplasia  of  fibrous 
tissue  between  the  glands  takes  place.  This  accounts  for  the 
thickening  of  the  mucosa.  In  many  cases  the  infiltration  and 
proliferation  occur  in  discrete  areas,  giving  rise  to  flat, 
prominent,  and  g'ranular  portions.  The  projecting  parts 
formed  by  the  fibrous  tissue  may  form  distinct  nipple-like 
prominences,  giving  rise  to  a  condition  called  ctat  mamelone. 


CHRONIC    ASTHENIC    GASTRITIS 


489 


Occasionally,  circumscribed  growths  made  up  of  mucoid  or 
glandular  tissue  may  form,  constituting  what  is  known  as 
gastritis  polyposa.  In  protracted  cases  the  hypersemia  dis- 
appears;  the  mucous   membrane   is   pale  gray   in  color;  the 


Fig.  66. — Gastric  catarrh:  fatty  degeneration  of  the  glands,  early  stage. 
From  a  photograph,  X  350.  From  a  case  of  pulmonary  tuberculosis. 
The  gastric  glands  are  swollen,  and  the  outlines  of  the  cells  are  com- 
pletely lost;  the  nuclei  have  disappeared  in  parts,  and  the  cells  are  more 
granular  than  normal,  fatty  granules  being  also  seen.  The  stroma  is 
normal.  From  a  preparation  hardened  in  Marchi's  fluid,  and  stained 
with  logwood.     (From  Sidney  Martin's  "  Diseases  of  the  Stomach.") 


glands  become  atrophied,  and  the  stroma  shrinks,  owing  to 
cicatricial  contraction. 

Symptomatology. — The  symptoms  of  a  mild  asthenic 
catarrh  of  the  stomach,  as  well  as  of  simple  HCl  excess  (hyper- 
chlorhydria),  are  frequently  entirely  wanting,  the  patient 
claiming  to  be  well ;  but  wdien  there  is  a  nervous  complication 
or  much  fermentation,  the  symptoms  will  be  briefly  those  of 
what  is  commonly  called  flatulent  dyspepsia.     They  include 


490 


THE    GASTRO-INTESTINAL    CLINIC 


fullness  and  vague  uneasiness,  amounting  sometimes  to  pain 
in  the  gastric  region,  coming  on  shortly  after  meals  and  fol- 
lo\^ed  a  little  later  by  more  or  less  copious  eructations  of  gas, 
which  may  be  sour  and  offensive  in  taste  and  smell.     There  is 


Fig.  67. — Atrophy  of  the  mucous  membrane  of  the  stomach  with  polyposis. 
a,  mucous  membrane,  normal  in  appearance;  b,  smooth  and  atrophied 
mucous  membrane;  c,  polypi.     (Ziegler.) 


usually  some  impairment  of  appetite,  which  may  go  on  to 
complete  anorexia  in  advanced  cases,  with  occasional  nausea. 
In  the  alcoholic  cases  and  those  complicated  by  marked  mus- 


CHRONIC    ASTHENIC    GASTRITIS 


491 


cular  atony  or  dilatation  of  the  stomach,  there  is  vomiting  of 
sour  fermenting  ingesta — sometimes  of  glairy  mucus  only. 
This  is  a  constant  symptom  in  those  cases  especially  which  are 
complicated  by  obstraction  to  the  onward  propulsion  of  the 
gastric  contents,  whether  in  the  pylorus  or  duodenum.      Spas- 


Fig.  68. — Fibrosis  in  gastric  catarrh.  From  a  photograph,  x  70.  From  a 
case  of  catarrh  in  pulmonary  tuberculosis.  The  gastric  glands  are  in  a 
state  of  atrophy,  and  are  widely  separated  by  recently-formed  connect- 
ive tissue,  rich  in  cells.  The  mucous  membrane  had  lost  its  epithelial 
lining.  The  other  coats  of  the  organ  were  normal.  From  a  preparation 
hardened  in  Marchi's  fluid,  and  stained  with  logwood.  (From  Sidney 
Martin's  "  Diseases  of  the  Stomach.") 

modic  or  mechanical  vomiting  is  rare  in  other  cases,  except 
in  acute  exacerbations.  Heartburn  and  water-brash  may  or 
may  not  be  present.  The  tongue  is  usually  more  or  less 
coated,  with  an  accompanying  bad  taste  in  the  mouth.  But 
none  of  these  symptoms  are  diagnostic.  You  may  have  a  foul 
tongue  and  breath  from  an  unhealthy  mouth  and  naso- 
pharynx, without  catarrh  of  the  stomach,  especially  when  there 
is  gastric  fermentation  from  other  causes ;  and,  on  the  con- 


492  THE    GASTRO-INTESTINAL    CLINIC 

trary,  there  may  be  a  clean  tongue  and  the  absence  of  bad 
taste  or  belching  with  a  pronounced  gastric  catarrh,  though  it 
is  tri^ith  to  say  that  this  latter  combination  is  much  more  rarely 
seen  in  the  form  of  gastritis  now  under  consideration  than  in 
the  acid  form,  in  which  there  is  uniformly  present  an  excessive 
secretion  of  the  gastric  juice,  along  with  a  large  quantity  of 
mucus. 

Many  and  diverse  nervous  symptoms,  including  frequently 
out-and-out  neurasthenia,  nearly  always  complicate  fully  de- 
veloped and  advanced  gastric  catarrh,  and  when  the  case  has 
not  been  properly  treated  in  the  beginning,  the  intestines  are 
sooner  or  later  affected.  Then  either  constipation  or  diarrhea, 
or  these  two  conditions  in  alternation,  will  almost  surely 
develop. 

Diagnosis. — It  is  not  possible  to  make  a  certain  diagnosis  of 
chronic  asthenic  catarrh  of  the  stomach  without  the  use  of  the 
tube  and  the  more  important  quantitative  tests  of  the  stomach 
contents  described  in  Lecture  X.  The  advanced  cases  with 
vomiting  and  pain  can  easily  be  confounded  with  cancer  or 
ulcer,  and  the  earlier  or  milder  ones  are  constantly  mistaken 
for  nervous  dyspepsia.  Then,  even  when  occasional  vomiting 
of  large  amounts  of  mucus  without  coexisting  pain,  tumor, 
cachexia,  or  emaciation  makes  it  probable  that  a  catarrhal  in- 
flammation exists  rather  than  either  ulcer  or  malignant  disease, 
you  would  have  no  means  of  determining,  except  by  testing 
the  stomach  contents,  whether  the  process  were  on  the  one 
hand  a  proliferating  one,  accompanied  by  an  excessive  secre- 
tion of  HCl  and  demanding  the  blandest  possible  diet  with 
alkalies  and  sedatives  in  the  way  of  medication,  or,  on  the 
other  hand,  the  contrary  condition  of  degenerating  glands  and 
a  lessening  of  the  HCl  and  ferments,  which  would  call  for  a 
more  stimulating  diet  and  a  more  decidedly  tonic  medication, 
including  the.  mineral  acids,  pepsin,  antiseptics,  and  astringents. 
Besides,  while  in  acid  gastric  catarrh  abdominal  massage 
would  be  contra-indicated  except  in  the  form  of  the  lightest  and 
most    superficial    rubbing    (effleurage),    in    chronic    asthenic 


CHRONIC    ASTHENIC    GASTRITIS  493 

catarrh  of  the  stomach  energetic  kneading  (petrissage)  of  the 
whole  epigastric  region  is  very  beneficial  and  often  a  curative 
agent  of  the  utmost  value. 

The  sample  of  stomach  contents  brought  up  an  hour  after 
the  Ewald  test  breakfast  will  show  you  at  a  glance  whether 
the  meal  has  been  properly  digested  into  a  uniform  thin  fluid, 
as  well  as  give  you  a  rough  idea  of  the  amount  of  mucus  in 
the  organ  and  its  probable  source,  and  will  enable  you  to 
ascertain  by  chemical  tests  the  total  acidity,  the  proportions  of 
free  and  combined  HCl,  the  presence  or  absence  of  lactic  acid, 
the  amount  and  activity  of  the  pepsin  and  rennet  ferment 
present,  and  the  extent  to  which  the  starch  has  been  converted 
by  the  salivary  ferment.  By  a  microscopic  examination  you 
would  learn  the  degree  of  microbic  infection,  and  something 
as  to  the  condition  of  the  epithelium. 

All  this  and  more  you  can  do  if  you  wish  to  be  very 
thorough,  but  if  you  will  merely  determine,  by  the  simple 
tests  already  described,  the  total  acidity  and  the  amount  of  free 
HCl,  if  any,  you  will  be  able  to  decide  whether  in  case  of  a 
great  abundance  of  mucus  you  are  dealing  with  an  acid  or 
asthenic  catarrh  of  the  stomach  with  a  deficiency  of  the  acid 
gastric  juice.  With  a  percentage  of  free  HCl  of  .060  to  .100 
or  more,  and  much  mucus  which  you  are  able  to  saitsfy  your- 
self beyond  reasonable  question  is  of  gastric  origin,  you  should 
infer  an  acid  gastritis.  If  the  free  HCl  is  constantly  below 
.040  under  the  same  conditions,  the  catarrh  would  be  of  the 
asthenic  type.  If  the  percentage  were  between  these  figures 
the  form  of  gastritis  would  have  to  be  determined  by  the 
microscopic  findings  or  the  later  developments  of  the  case. 
In  case  free  HCl  should  be  absent,  you  should  test  for  lactic 
acid,  which  if  present  in  decided  amount  even  after  a  Boas 
oatmeal,  milk-free  test  breakfast,  would  awaken  a  suspicion  of 
cancer.  If  there  is  an  entire  absence  of  mucus  in  the  sample 
of  contents  brought  up,  and  especially  if  none  appears  in  the 
wash  water  during  lavage  when  the  stomach  is  empty  of  food, 
there   is   not   likely  to   be   any   inflammation   of   the   gastric 


494  THE    GASTRO-INTESTINAL    CLINIC 

mucous  membrane  (though  it  might  be  in  the  terminal  stage 
of  atrophy),  and  any  aberration  from  the  normal  in  the 
amount  of  the  HCl  and  ferments  could  then  be  attributed  to 
nervous  causes ;  but  in  the  case  of  the  almost  entire  absence  of 
all  the  elements  of  the  gastric  juice,  including  the  rennet 
ferment  with  a  total  acidity  of  not  over  lo  or  12,  you  would 
consider  the  possibility  of  gastric  atrophy,  especially  if  the 
patient  were  very  anaemic  and  emaciated,  and  cancer  could  be 
excluded.  You  will  notice  that  I  use  here  the  word  possibility, 
not  probability;  for  experience  has  taught  me  that  many  cases 
may  have  practically  no  gastric  juice  for  many  months  and 
yet,  under  proper  treatment,  later  show  a  return  of  it. 

But  in  case  you  find  in  the  sample  of  stomach  contents  a 
moderate  amount  only  of  mucus,  and  you  do  not  obtain  any 
fragments  which  under  the  microscope  reveal  diseased  epi- 
thelium, the  question  is  not  yet  settled.  You  will  then  need 
to  proceed  to  wash  out  the  stomach,  following  the  methods 
described  in  Lecture  XXIX.  If  then,  after  cleansing  away 
all  remains  of  food  and  any  coarse  lumps  of  mucus  found 
which  will  have  usually  been  swallowed,  you  bring  up  more 
which  is  thinner,  paler,  and  in  fine  flakes  or  delicate  strings, 
you  may  decide,  according  to  Riegel  and  others,  that  it  comes 
from  the  gastric  mucous  membrane  and,  therefore,  signifies 
chronic  catarrh  of  the  stomach. 

According  to  my  own  experience,  however,  this  may  in- 
dicate only  a  transient  catarrhal  process,  involving  some  one  or 
more  portions  of  the  gastric  membrane  and  capable  under 
treatment  of  complete  cure  within  a  few  days,  just  as  often 
happens  with  slight  catarrhal  attacks  in  the  nose  and  throat. 
My  reason  for  this  opinion  is  that  I  have  frequently  seen  such 
mucus  at  the  first  lavage,  which  after  washing  out  three  or 
four  times  disappeared  entirely,  so  that  subsequent  washings 
brought  up  no  mucus  at  all.  A  diagnosis  of  chronic  gastric 
catarrh  cannot,  therefore,  be  positively  based  upon  even  the 
symptoms  and  macroscopic  findings  in  the  wash  water  com- 
bined until  after  at  least  three  or  four  washings,  unless  the 


CHRONIC    ASTHENIC    GASTRITIS  495 

symptoms  are  very  pronounced,  as  in  serious  cases,  or  the 
amount  of  mucus  is  very  large.  Fragments  which  under  the 
microscope  may  show  the  condition  of  the  epithehum  are  more 
hkely  to  be  found  in  the  wash  water  after  lavage  than  in  por- 
tions of  the  stomach  contents  after  test  meals.  But  this,  too, 
is  a  somewhat  uncertain  dependence,  and  negative  results, 
such  as  finding  pieces  of  glandular  tissue  showing  normal  cells, 
or  the  failure  to  find  degenerated  cylindric  cells  from  the 
gastric  mucosa  at  one  or  two  examinations,  is  no  proof  of  the 
integrity  of  the  entire  membrane.  In  deciding  between  a 
mild  gastritis  and  nervous  dyspepsia,  you  should  remember 
that  in  the  latter  affection  the  symptoms  are  usually  change- 
able and  subject  to  remissions,  while  even  in  the  mildest  gas- 
tritis they  are  likely  to  be  more  constant. 

The  prognosis,  like  that  of  the  acid  form,  is  good  or  bad 
according  to  the  stage  and  grade  of  the  afTectioh  as  well  as 
the  age  of  the  patient,  and  according  to  the  ability  and  willing- 
ness of  the  latter  to  make  sacrifices  and  patiently  carry  out  a 
somewhat  troublesome  treatment.  Those  who  desire  to  be 
cured  without  help  from  a  tube,  and  especially  without  much 
change  from  the  habits  of  eating,  drinking,  and  exercising,  or 
more  often,  not  exercising,  which  brought  the  disease  upon 
them,  may  be  safely  promised  that  they  will  keep  their  gastric 
catarrh  to  the  end  of  their  lives,  which  will  generally  be  con- 
siderably shortened  thereby.  Cases  in  which  the  glandular 
structures  have  not  been  much  damaged,  and  in  not  too  old  or 
debilitated  persons,  can  usually  be  cured  in  a  few  months,  when 
the  proper  treatment  is  faithfully  and  persistently  carried  out. 

In  the  milder  cases  which  are  not  easily  distinguishable  from 
simple  lack  of  HCl  (hypochlorhydria  of  assumed  nervous 
origin),  recovery  should  always  take  place,  when  the  patients 
can  be  fully  controlled  in  all  their  habits. 


LECTURE  XLVIII 

THE  TREATMENT  OF  CHRONIC  AS- 
THENIC GASTRITIS  (CHRONIC  GAS- 
TRIC   CATARRH) 

The    Treatment:    Dietetic   and    Hygienic As    in   chronic 

acid  gastritis,  so  in  the  more  famihar  form  of  chronic  gastric 
catarrh  with  depression  of  the  glandular  function,  you  will 
need  to  guard  the  patient  always  against  foods  and  drinks  of 
a  decidedly  irritating  character,  as  well  as  the  more  ferment- 
able ones,  which  tend  to  aggravate.  In  the  asthenic  form, 
however,  the  necessity  of  keeping  to  the  blandest  articles  is 
very  much  less.  The  milder  condiments  can  sometimes  be 
taken  with  advantage,  since  they  stimulate  the  appetite,  and  at 
first  increase  motility  somewhat.  Small  doses  of  the  sour 
wines  may  be  well  borne  in  a  certain  proportion  of  cases ;  and 
strictly  limited  doses  of  a  good  malt  preparation,  such  as 
Hoff's  Malt  Extract,  not  exceeding  two  ounces,  taken  with 
meals  containing  much  starch  food,  will  usually  prove  safe  and 
often  helpful.  But  a  free  use  of  any  of  these  things  will 
surely  be  injurious. 

In  no  disease  is  it  more  emphatically  true  that  the  patient, 
not  the  disease,  needs  to  be  treated.  In  arranging  the  diet  of 
patients  with  catarrh  of  the  stomach,  hard-and-fast  rules  can 
rarely  be  applied  with  safety.  Each  case  by  itself  needs  to  be 
closely  watched  and  the  secretions  and  excretions,  especially 
the  gastric  juice  and  urine,  should  be  carefully  studied.  If 
you  attempt  to  follow  in  all  your  cases  the  hobbyists  who  ad- 
vise an  exclusive  milk  diet,  the  use  of  meat  and  hot  water  only, 
or  a  reliance  on  cereals,  vegetables,  fruits,  nuts,  etc.,  (the  so- 

496 


TREATMENT    OF    CHRONIC    ASTHENIC    GASTRITIS  497 

called  natural  diet),  you  will  very  frequently  be  disappointed, 
particularly  with  the  last-mentioned  group  of  foods. 

There  are  comparatively  few  positive  indications  and  con- 
tra-indications.  The  articles  that  most  frequently  disagree 
markedly  are  those  containing  cane  sugar,  all  forms  of  fresh 
yeast  bread,  rolls,  etc.,  and  the  ordinary  beers  and  malt  liquors 
generally  in  the  amounts  usually  taken,  because  of  their  prone- 
ness  to  rapid  fermentation.  Vinegar,  pickles,  cabbage,  green 
corn,  beans,  shellfish,  fried  things,  and  all  very  coarse,  tough, 
or  hard  substances  which  cannot  be  finely  divided  by  the  teeth 
and  well  masticated,  are,  as  a  rule,  unsuited  to  these  cases. 
Very  much  will  depend  upon  the  stage  of  the  disease,  the 
state  of  the  nerve  centers,  and  the  strength  of  the  muscular  sys- 
tem; also  upon  the  other  treatment.  For  example,  when  a 
patient  can  spend  some  hours  daily  in  rowing,  pulley  exer- 
cises, or  other  gymnastics  for  the  trunk  muscles,  horseback  rid- 
ing, walking,  or  bicycling,  and  have  in  addition  sponge  baths 
and  lavage  as  well  as  abdominal  massage,  a  very  much  more 
liberal  variety  of  diet  can  be  allowed  than  would  be  prac- 
ticable if  there  should  be  so  little  vigor  of  the  muscles,  nerves, 
and  circulation  as  to  compel  the  adoption  for  a  time  of  the 
rest  treatment. 

Generally,  I  enjoin  the  avoidance  of  all  the  objectionable 
articles  above  mentioned,  as  well  as,  in  bad  cases,  most  of  the 
vegetables,  except  in  the  puree  form ;  but  I  have  seen  excep- 
tional cases  in  which  there  was  a  very  feeble  heart,  marked  mal- 
nutrition on  account  of  associated  intestinal  catarrh,  and  an 
intolerance  of  the  stomach  tube,  so  that  the  usual  course  of 
treatment  had  to  be  departed  from  in  various  ways.  Both 
lavage  and  the  customary  restrictions  in  the  diet,  including  a 
denial  of  sweets,  were  here  followed  by  increased  emaciation 
and  debility.  Therefore,  the  most  nutritious  foods  were  se- 
lected, and,  besides  much  milk,  cream,  eggs,  meat  juice, 
chopped  beef,  purees  and  the  finer  cereals,  some  sugar  even 
had  to  be  allowed  in  order  to  maintain  nutrition,  while  massage 
and  the  Nauheim  resisted  movements,  with   some  cautious 


498  THE    GASTRO-INTESTINAL   CLINIC 

medication,  were  relied  upon  mainly  in  the  way  of  treatment, 
and  with  ultimate  success. 

In  general  the  best  course  as  to  diet  is  to  nourish  as  fully  as 
possible  without  risking  excessive  fermentation  and  without 
irritating  or  overburdening  the.  digestive  organs,  bearing  in 
mind  that  a  part  of  the  food  is  lost  through  the  fermentative 
and  putrefactive  processes  in  these  cases. 

Three  to  five  moderate  or  small  meals  a  day  are  best  in 
most  cases,  especially  when  the  motility  of  the  stomach  is 
weak.  Exceptionally  two  meals  are  better.  They  should  be 
eaten  when  the  patient  is  free  from  worry  and  fatigue,  and  in 
as  cheerful  company  as  possible.  Above  all,  it  is  necessary 
that  plenty  of  time  should  be  taken  for  meals,  the  food  being 
most  thoroughly  masticated  and  insalivated. 

Beverages — As  to  the  kind  and  quantity  of  liquid  to  be 
taken  at  meals,  no  inflexible  rule  can  be  made.  Strong  coffee 
and  tea  are  drugs  rather  than  foods,  and  are  likely  to  do 
.  harm,  at  least  in  the  end,  though  they  are  sometimes  toler- 
ated well  for  a  time;  and  well-roasted  coffee  has  been  proved 
to  exert  some  antiseptic  action.  Chocolate  is  even  more  in- 
digestible. The  lighter  forms  of  cocoa,  especially  an  infusion 
of  cocoa  shells,  more  frequently,  agree.  .  Cereal  coffees,  with 
good  cream  or  milk,  suit  well  in  most  cases,  and  a  mixture  of 
milk  and  hot  water  flavored  to  the  taste  may  generally  be  per- 
mitted. Claret  and  water  or  other  light  wine  may  prove 
safe,  and  even  useful,  when  there  is  no  lithjemia  or  very  high 
acidity  in  the  urine.  The  amount  of  any  fluid  taken  with  the 
meal  must  be  strictly  limited,  especially  when  the  stomach  is 
dilated  or  has  weak  expulsive  power.  A  comparatively  dry 
diet  is  often  then  the  best — a  daily  allowance  of  one  to  two 
pints  of  liquid  taken  between  meals. 

The  general  hygienic  requirements  include  an  abundance 
of  pure  outdoor  air  and  sunshine.  Therefore  the  seashore, 
mountains,  or  country  will  be  the  best  place  of  residence — 
much  better  than  any  crowded  city.  Fatiguing  indoor  or 
sedentary   occupations   and   excess  of   every  kind   should  be 


TREATMENT  OF   CHRONIC   ASTHENIC   GASTRITIS  499 

avoided  and  there  should  be  plenty  of  sleep  in  large,  well- 
ventilated  rooms.  Exercise  out  of  doors  is  really  essen- 
tial to  a  cure,  and  must  be  taken  by  all  except  in  the  weakest 
cases. 

Mechanical  Forms  of  Treatment. — Lavage  is  probably  the 
most  useful  of  all  the  curative  measures.  When  the  amount 
of  mucus  and  germ  infection  is  great,  it  should  be  done 
every  day  (Riegel  says  twice  a  day),  preferably  in  the  morn- 
ing before  breakfast.  Plain,  sterilized  warm  water  will  often 
answer  w^ell  enough,  but  the  addition  of  table  salt,  two  tea- 
spoonfuls  to  the  quart,  will  render  it  more  efficacious.  Drink- 
ing a  pint  or  more  of  warm  water,  followed  by  vigorous  con- 
tractions of  the  diaphragm  and  abdominal  muscles,  with  the 
patient  in  different  postures  as  hitherto  described,  so  as  to 
detach  adherent  mucus  from  the  walls  of  the  stomach,  is  a 
most  helpful  preliminary  to  the  washing-out  process.  After 
passing  one  or  two  cjuarts  of  salt  solution  into  and  out  of  the 
stomach,  a  solution  of  resorcin  or  of  alum,  half  a  teaspoonful 
to  the  quart,  or  of  nitrate  of  silver,  3  or  4  grains  to  the  pint, 
may  be  introduced  and  cjuickly  withdrawn  in  the  more  stub- 
born cases  with  advantage.  Any  remains  of  the  silver  nitrate 
should  be  removed  by  washing  out  further  with  plain  warm 
water,  which  is  better  than  a  solution  of  common  salt,  to  pre- 
vent any  possible  danger.  Dilute  HCl,  a  dram  or  dram  and 
a  half  to  the  quart,  has  worked  well  in  some  cases.  A  large 
number  of  other  astringent  and  antiseptic  drugs  has  been 
recommended  for  use  in  the  same  way,  and  one  will  some- 
times succeed  when  another  has  failed.  A  safe  rule  will  be  to 
employ  as  a  maximum  amount  at  one  time  not  more  than  ten 
times  the  usual  medicinal  dose  of  the  drug,  since  one-tenth  part 
of  the  solution  used  may  possibly  be  absorbed ;  dissolve  this 
in  at  least  a  pint,  and  better,  a  quart  or  more  of  water,  and 
then  remove  it  promptly  and  completely.  But  it  will  be  best 
to  begin  always  with  a  much  weaker  solution. 

Stomach  washing  should  not  be  done  too  often  (rarely 
oftener  than  once  a  day)   or  persevered  with  too  long.     As 


500  THE   GASTRO-INTESTINAL    CLINIC 

soon  as  the  mucus  lessens  markedly,  it  can  be  limited  to  thrice 
or  even  twice  a  week,  and  when  none  at  all  is  found,  it  is  bet- 
ter ^o  repeat  it  once  a  week  for  a  few  weeks  longer.  Even  if 
mucus  is  found  which  has  come  from  the  nasopharynx  or 
esophagus,  as  often  happens,  it  will  be  desirable  to  cleanse  it 
away  once  or  twice  a  week  until  the  local  catarrhal  process 
above  can  be  cured,  since  otherwise  its  presence  facilitates  the 
rapid  multiplication  of  bacteria  in  the  stomach,  and  thus 
keeps  this  organ  infected,  besides  doubtless  favoring  the  de- 
velopment of  catarrhal  inflammation  in  it. 

Washing  the  Stomach  Downward. — In  the  comparatively 
rare  cases  in  which  lavage  cannot  be  practiced,  something  in 
the  way  of  cleansing  the  stomach  can  be  accomplished  by  hav- 
ing the  patient  drink  two  glasses  of  hot  water  several  times 
a  day  an  hour  before  meals  with  the  view  of  washing  the 
mucus  downward.  This  cannot  be  safely  done,  however,  in 
dilatation  or  marked  motor  insufficiency  of  the  stomach,  since 
in  such  cases  the  viscus  does  not  readily  empty  itself  and  the 
increased  contents  would  only  further  embarrass  it.  In  the 
majority  of  cases  of  chronic  gastric  catarrh  with  a  deficiency 
of  HCl,  the  motor  power  of  the  organ  is  not  much  impaired,  at 
least  in  the  earlier  stages ;  but  at  the  best  the  warm  water 
drinking  is  much  less  efficient  than  lavage,  since  it  only  car- 
ries the  mucus  and  its  contained  bacteria  on  into  the  intes- 
tines, from  which  they  are  by  no  means  always  promptly  ex- 
pelled. 

In  Germany  the  saline  waters  of  Homburg,  Kissingen, 
and  Wiesbaden,  especially,  are  used  in  a  similar  way;  but 
my  observations  while  at  Homburg  did  not  impress  me 
very  favorably  with  the  value  of  the  routine  use  of  that  water 
in  gastric  catarrh.  Kissengen  water,  however,  I  have  found 
useful  in  this  disease,  especially  in  constipated  cases.  Pro- 
fessor von  Noorden  has  recently  borne  strong  testimony  to  the 
value  of  these  saline  waters  in  the  different  forms  of  gastric 
catarrh.^ 

1  "  Saline  Therapy,"  New  York,  E.  B.  Treat  &  Co.,  1904. 


TREATMENT    OF    CHRONIC    ASTHENIC    GASTRITIS  $01 

The  addition  of  salt  or  of  salt  and  soda  together  to  warm 
water  taken  internally  often  effects  good  results,  but  a  free  use 
of  these  remedies  internally  would  not  be  nearly  as  safe  as 
lavage. 

Modes  of  Stimulating  the  Gastric  Muscles. — In  connection 
with  diet  and  lavage,  skilled  massage  of  the  abdomen  is  as 
potent  for  good  in  this  form  of  gastritis  as  it  is  for  harm  in 
the  acid  form  and  in  simple  hyperchlorhydria.  One  of  the 
many  good  results  of  massage  of  this  region  is  a  strengthen- 
ing of  the  abdominal  muscles  as  well  as  the  muscular  walls 
of  its  contained  organs.  The  glandular  function  can  also  be 
powerfully  stimulated  thereby. 

These  objects  can  also  be  promoted  by  various  special  exer- 
cises and  forms  of  gymnastics.  Rowing  is  one  of  the  best  of 
these,  and  an  excellent  substitute  is  the  use  of  pulleys,  espe- 
cially those  made  with  elastic  rubber  cords,  which  afford  a 
yielding  resistance.  There  are  also  numerous  bendings  and 
twistings  of  the  body  which  do  not  require  apparatus  of  any 
kind,  and  yet  are  very  useful  in  developing  the  trunk  muscles 
and  the  muscular  walls  of  the  abdominal  viscera.  They  are 
described  and  pictured  in  works  on  physical  culture  and  a 
number  of  them  are  described  in  Lecture  XXIII.  Most  out- 
door sports,  especially  golf  and  .tennis,  are  helpful  in  the 
same  direction,  and  it  should  be  borne  in  mind  that  in  pro- 
portion as  the  muscles — especially  those  of  the  abdomen — are 
developed,  all  the  atonic  forms  of  indigestion,  including  gas- 
tric catarrh,  become  milder  and  more  manageable,  provided 
always  a  proper  diet  and  other  hygienic  requirements  are  ob- 
served. 

Electricity  is  less  useful  in  this  disease  than  in  acid  gastri- 
tis, but  when  asthenic  catarrh  of  the  stomach  is  complicated 
with  dilatation,  as  in  many  of  the  severer  cases,  intragastric 
faradization  with  the  ordinary  current  from  a  coarse  coil  and 
with  slow  interruptions  can  do  great  good.  Combined  with 
very  careful  diet  helped  out  by  rectal  feeding,  and  with  regular 
lavage  and  massage,  I  have  seen  it  rescue  cases  from  the  brink 


502  THE    GASTRO-INTESTINAL    CLINIC 

of  the  grave.  This  procedure  is  fully  discussed  in  Lecture 
XXX.  on  Intragastric  Electricity,  and  an  illustration  is  there 
given  of  the  intragastric  electrode  as  modified  by  myself. 

Medicinal  Treatment. — Drugs  internally  are  much  less  use- 
ful here  than  the  agencies  already  described.  Laxatives  need 
sometimes  to  be  prescribed,  though  the  hygienic  measures  and 
mechanical  forms  of  treatment  described  in  Lecture  LXX. 
will  often  overcome  the  constipation.  It  is  indispensable  that 
there  should  be  regular  and  complete  evacuations  of  the  bowels. 
HCl  and  pepsin  in  moderate,  or  sometimes  even  large,  doses 
are  usually  important  adjuvants  in  not  too  advanced  cases,  and 
may  be  of  marked  palliative  value,  even  in  the  stage  of  atrophy. 
The  manner  of  using  these  is  fully  explained  in  Lecture  XXXI. 
Nitrate  of  silver,  ^  grain,  combined  with  5-  to  lo-grain  doses 
of  bismuth,  may  occasionally  do  good,  and,  when  the  patient 
has  to  forego  the  advantages  of  lavage,  a  little  help  toward  les- 
sening the  fermentation  can  often  be  obtained  from  antiseptic 
drugs,  of  which  one  of  the  most  efficient  and  least  hurtful,  if 
not  pushed  too  long,  is  carbolic  acid  in  i-  to  2-minim  doses 
after  meals,  given  with  glycerin  and  guarded  with  spirits  of 
chloroform,  compound  tincture  of  cardamom,  and  peppermint 
but  not  when  nephritis  complicates. 

Resorcin  in  2-  to  5-grain  doses  and  sulpho-carbolate  of  zinc 
in  the  same,  or  larger  ones,  have  been  much  vaunted  and  will 
sometimes  lessen  the  fermentation,  but  in  my  experience  they 
have  frecjuently  been  disappointing. 

The  nausea  is  best  controlled  by  diet  and  lavage,  but  when 
the  latter  is  impracticable,  minute  doses  of  calomel  and  ipecac 
will  often  afford  relief.  Bismuth  and  carbolic  acid,  well 
flavored  in  a  mixture  as  follows,  have  served  me  well  in  such 
cases : 

IJ    Bism.   subnit 3i 

Glycerit  ac.  carbol f  3  ss 

Sps.  chloroform      K^ ^^.^^ 

Tr.  cardam.  com.  ) 

Aq.   menth.  pip.,  q.  s.  ad f^ii 

M.     Sig.      Teaspoonful    in  water  or  limewater  every 
.     two  hours  till  relieved. 


TREATMENT    OF    CHRONIC    ASTHENIC    GASTRITIS  503 

The  failure  of  appetite  is  usually  best  overcome  by  lavage 
and  the  administration  of  pepsin  and  HCl,  but  in  stubborn 
cases  may  sometimes  be  helped  by  tincture  of  nux  vomica,  gen- 
tian, quassia,  or  columbo,  and  the  Germans  recommend  very 
strongly  condurango.  I  have  recently  seen  the  appetite  and 
digestion  both  improved  by  5-grain  doses  of  orexin  tannate, 
taken  an  hour  before  meals.  This  remedy  seems  to  increase 
the  secretion  of  HCl. 

To  sum  up :  By  far  the  most  effective  single  method  of 
treatment  is  lavage,  which  the  majority  of  patients  soon  learn 
to  tolerate  without  inconvenience,  unless  there  coexists  se- 
rious disease  of  the  heart  or  blood-vessels.  There  are  a  few 
other  contra-indications  which  have  been  detailed  elsewhere. 
Next  comes  diet.  Third  in  the  order  of  efficacy  may  be  placed 
the  copious  drinking  of  hot  water  to  wash  the  mucus  downward, 
when  the  motor  power  of  the  stomach  is  good  enough  to  render 
this  safe.  In  the  cases  complicated  with  much  motor  insuffi- 
ciency and  still  more  with  pronounced  dilatation,  intragastric 
faradization  must  take  the  third  place,  and  sometimes,  indeed, 
it  can  accomplish  even  more  than  lavage,  though  both  are  here 
often  indispensable.  Massage  and  special  gymnastics  should 
rank  at  least  as  high  as  fourth  in  curative  power,  and  drugs 
internally  administered  are  least  effective  of  all,  except  to  com- 
bat special  symptoms. 

Naturally,  the  combination  of  all  the  more  valuable  agencies, 
including  especially  lavage,  diet,  massage  and  gymnastics,  of- 
fers the  most  promise  of  speedy  cure,  and  spending  several 
hours  daily  in  the  open  air  and  sunshine  in  some  healthful 
climate  must  in  all  cases  contribute  largely  to  effect  that  resulto 


LECTURE  XLIX 

CHRONIC    STHENIC    GASTRITIS    (ACID 
GASTRIC   CATARRH) 

It  may  be  considered  as  now  established  that  there  are  at 
least  two  widely  different  types  of  chronic  gastritis — the 
sthenic  and  the  asthenic — those  with  an  excessive  secretion  of 
HCl,  and  usually  of  the  digestive  ferments,  and  those  with  a 
deficiency  or  absence  of  the  same.  Further  subdi^•isions  have 
been  made;  and,  in  particular,  there  have  been  described  a 
mucous,  a  hypertrophic,  and  an  atrophic  glandular  gastritis; 
but  the  last-named  is  present  in  the  terminal  stage  of  most 
at  least  of  the  asthenic  forms  and  exceptionally  may  occur  at 
the  end  of  the  sthenic  ones. 

Chronic  sthenic  gastritis — acid  gastric  catarrh^has  often 
been  described  among  the  gastric  neuroses,  the  accompanying 
inflammatory  condition  having  been  o^•erlooked ;  but  there  is 
nothing  neurosal  about  it  except,  possibly,  a  predisposition  to 
it  in  nervous  persons,  and  its  injurious  effects  upon  the  nervous 
system.  Once  established,  it  is  one  of  the  most  constant,  per- 
sistent, and  even  stubborn  of  gastric  diseases.  It  affects  very 
often  persons  of  a  nervous  temperament,  though  is  by  no 
means  confined  to  them,  and  the  original  nen^ousness  of  its 
victims  is  aggravated  by  the  damaging  effect  which  the  ex- 
cessively acid  chyme  has  upon  intestinal  digestion,  the  gastric 
and  intestinal  mucous  membrane,  and  the  peristalsis. 

As  to  its  cctiology,  the  neuropathic  constitution  seems  to  be  a 
decidedly  predisposing  factor,  and  since  it  occurs  far  more 
frequently  among  brain- workers  than  among  those  who  work 
mainly  with  their  muscles,  there  is  probably  ground  for  the 
opinion  of  ]\Iathieu,  and  other  French  authors,  that  intellectual 

504 


CHRONIC    STHENIC    GASTRITIS  505 

overwork  may  be  one  cause.  ]\Iathieu  advises  sexual  rest  in 
the  treatment  of  the  affection,  and  would  therefore  doubtless 
include  excesses  in  venery  among  the  predisposing  causes. 
However  this  may  be,  it  is  suggestive  that  of  the  large  number 
of  cases  of  acid  gastric  catarrh  that  have  been  studied  by  me, 
the  great  majority  have  been  in  the  persons  of  respectable 
widows,  maiden  ladies,  continent  widowers  and  bachelors,  and 
married  men  of  advanced  years,  in  whom  sexual  desire  has 
possibly  outlived  potency.  Sexual  erethism,  then,  hae  seemed 
a  markedly  predisposing  condition.  In  the  minority  of  cases 
there  was  usually  a  history  of  excessive  mental  or  nervous 
strain,  with  irregular  and  rapid  eating.  It  is  probable,  too, 
that  the  prevalent  use  of  very  highly  seasoned  foods  and 
stimulating  drinks,  especially  the  sharper  spices  and  condi- 
ments, as  well  as  strong  coffee  and  tea,  by  persons  in  w^hom 
the  gastric  secretion  is  always  abundant  enough  without  such 
irritants  and  in  whom  the  nervous  supply  of  the  glandular  ap- 
paratus, as  well  as  the  nervous  system  generally,  is  excessively 
sensitive  and  hyperexcitable,  must  conduce  to  the  overaction 
of  the  gastric  glands,  and  finally  to  proliferation  of  them. 

There  are  also  certain  reflex  causes  of  excessive  secretion 
of  HCl  and  indirectly  probably  also  of  acid  gastritis.  The  one 
most  frequently  observed  by  me  is  movable  kidney,  and  I  have 
also  seen  cases  in  which  the  percentage  of  HCl  fell  to  less  than 
normal  after  a  gastroptosis  had  been  overcome  by  strapping 
with  adhesive  plaster.  Numerous  observers  testify  to  the  in- 
fluence of  gall  stones  and  renal  calculi  in  producing  hyperchlor- 
hydria.  Some  of  the  gynecologists  include  endometritis,  and 
the  oculists  eye-strain  among  the  possible  causes.  Reason- 
ing by  analog}',  I  should  think  that  any  of  these  last  might 
reflexly  excite  an  excessive  secretion  of  HCl,  but  do  not  be- 
lieve they  are  so  efficient  in  that  direction  as  those  affections 
previously  mentioned. 

Pathology. — In  Lecture  XLVIL,  on  Chronic  Asthenic  Gas- 
tritis, I  have  discussed  to  some  extent  the  pathology  of  the  pro- 
liferative or  sthenic  form  of  chronic  srastritis  as  well  as  that  of 


506  THE    GASTRO-INTESTINAL    CLINIC 

the  ordinary  gastric  catarrh  with  an  atrophic  tendency.  It 
would  certainly  seem  to  have  a  sufficient  anatomic  basis  to  war- 
rant its  separate  consideration.  Professor  George  Hayem  of 
Paris,  who  has  investigated  the  subject  of  the  inflammations  of 
the  gastric  mucosa  more  exhaustively  than  any  other  man,  had 
this  to  say  about  the  form  now  under  discussion  in  a  com- 
munication which  he  sent  me  for  publication  as  part  of  a 
symposium  on  Hyperchlorhydria  which  appeared  in  the  Inter- 
national Medical  Magazine  for  June,  1903  : 

"  The  only  glandular  modifications  the  relations  of  which 
with  hyperchlorhydria  are  well  demonstrated  are  of  an  irrita- 
tive variety.  They  are  the  kind  we  find  in  the  different  forms 
of  parenchymatous  gastritis  which  I  have  described.  This 
form  of  gastritis,  which  is  a  fairly  common  condition,  is  either 
pure  or  mixed ;  and  it  is  either  irritative  or  both  irritative  and 
degenerative.  The  pure  unmixed  is  the  rarer.  It  is  charac- 
terized by  a  general  hypertrophy  of  the  mucosa  and  by  an  active 
proliferation  of  the  glandular  elements.  The  excess  of  secre- 
tion usually  accompanying  this  variety  of  gastritis  is  manifestly 
the  consequence  of  the  richness  of  the  mucosa  in  glandular 
elements.  In  the  advanced  phases  of  this  form  of  gastritis 
and  in  mixed  gastritis  with  atrophy,  the  gastric  juice  becomes 
less  and  less  abundant  as  the  glandular  atrophy  progresses. 
The  special  changes  in  the  glands  that  persist  explain  why 
there  may  still  exist  a  marked  degree  of  hyperchlorhydria  with 
deficient  secretion.  Contrary  to  current  views  the  excessive 
liberation  of  HCl  during  the  course  of  digestion  is  not  due 
to  the  multiplication  of  border  cells ;  pathologic  anatomy  tends 
rather  to  show  that  these  chemical  changes  are  connected  with 
proliferation  of  the  principal  cells." 

The  symptoms  alone  will  not  enable  you  to  make  the 
diagnosis  of  sthenic  gastritis.  An  analysis  of  the  stomach 
contents  after  a  test  meal  is  always  necessary  before  a  positive 
decision  can  be  reached.  In  the  earlier  stages,  and  even  in 
fully  developed  cases,  there  are  often  no  symptoms  except  those 
referred  to  the  intestines  or  to  the  nervous  system.     Prominent 


CHRONIC    STHENIC    GASTRITIS  507 

among  the  latter  is  a  disturbance  of  sleep  which  may  amount 
to  obstinate  insomnia  or,  as  is  more  common,  only  to  an  uneasy, 
restless  sleep,  with  the  habit  of  awakening  entirely  at  a  very 
early  hour  of  the  morning.  A  majority  of  patients  who,  while 
blessed  with  a  sharp  appetite  and  a  craving  for  meats 
especially,  are  irritable  and  excitable  and  unable  to  sleep  after 
four  or  five  o'clock  a.  m.,  will  be  found  to  be  suffering  from 
hyperchlorhydria,  with  or  without  gastritis  of  the  proliferative 
type.  When  the  sleep  is  promptly  helped  by  a  teaspoonful 
»  dose  of  bicarbonate  of  soda  taken  at  bedtime,  it  may  be  set 
down  as  reasonably  certain  that  the  cause  of  the  trouble  is 
hyperacidity  of  some  kind,  and  frequently  it  is  the  form  under 
consideration. 

There  is  nearly  always  a  high  degree  of  nervous  erethism, 
with  at  first  much  mental  activity;  but  later  there  may  be 
depression;  also  intestinal  flatulence  and  often  gastric  flatus 
as  well,  and  either  constipation  or  diarrhea — generally  at  first 
constipation  and  later  sometimes  diarrhea  alternating  with 
constipation,  though  exceptionally  the  bowels  may  continue  to 
act  normally,  even  in  an  advanced  stage  of  the  disease.  The 
appetite  is  usually  good  and  is  often  excessive,  though  it  may 
be  deficient.  Emaciation  and  pallor  indicating  anaemia  and 
failing  nutrition  always  develop  at  some  stage  of  the  marked 
cases  that  are  not  arrested  early.  In  a  considerable  proportion 
of  the  bad  cases  there  is  a  more  or  less  severe  burning  pain, 
especially  at  the  height  of  digestion,  though  it  may  come  on 
at  any  time  during  the  digestive  period  and  last  till  the  stomach 
empties  itself  either  by  vomiting  or  propulsion  into  the  duo- 
denum, unless  relieved  by  alkalies  or  anodynes.  In  both 
simple  hyperchlorhydria  and  acid  catarrh  which  persist  for  a 
length  of  time,  chlorosis  is  more  likely  to  develop  than  when 
the  gastric  secretion  is  normal  (Riegel,  Cantu,  Bouveret, 
Hemmeter). 

Spasm  of  the  pylorus  frequently  results  from  the  irritant 
action  of  the  excessively  acid  gastric  contents,  with  stagnation 
and  retention  of  food,  and  secondary  dilatation  of  the  stomach, 


So8 


THE    GASTRO-INTESTINAL    CLINIC 


just  as  it  occurs  in  obstructive  stenosis  of  the  gastric  outlet. 
Before  i?s  walls  have  weakened,  there  may  be  violent  and  ex- 
cessively painful  cramps  of  the  stomach  from  the  same  cause. 
Since  salivary  digestion  is  arrested  very  early  in  the  stomach 
in  this  disease,  there  is  likely  to  be  a  large  amount  of  fermenta- 
tion of  the  starchy  foods.  In  decided  cases  this  takes  place 
not  only  in  the  stomach,  but  also  in  the  small  intestine,  since 
the  gastric  contents  continue  acid  after  passing  through  the 


Fig,  69. — Columnar  cells  and  yeast  fungi  found  in  the  wash  water 
from  a  case  of  chronic  acid  gastritis. 

pylorus  and  thus  inhibit  the  action  of  the  pancreatic  and  in- 
testinal juices,  which  require  an  alkaline,  neutral,  or  at  least  a 
merely  slightly  acid  medium. 

The  yeast  fungi  seem  to  thrive  in  spite  of  the  largest  per- 
centage of  HCl  ever  found  in  the  gastric  juice,  and  in  all  the 
typical  cases  of  sthenic  gastritis  that  I  have  studied,  the  micro- 


CHRONIC    STHENIC    GASTRITIS 


509 


scope  has  revealed  myriads  of  them  in  every  shde  prepared 
with  a  drop  of  the  stomach  contents,  especially  if  obtained 
toward  the  end  of  the  digestive  period. 

(See  accompanying  illustrations,  Figs.  69  and  70,  from  a 
case  under  the  care  of  the  author.) 

The  diagnosis  of  acid  gastric  catarrh  is  established  by  find- 
ing upon  repeated  analyses  of  the  gastric  contents  obtained  an 
hour  after  the  Ewald  test  breakfast,  either  a  full  normal  amount 
or  an  excess  of  free  HCl  upwards  of  0.70  to  o.i  or  even  0.2  to 


Fig.    70.— Yeast  fungi   and    columnar    epithelium   from   a   case   of  acid 

gastritis. 

0.3  per  cent. — along  with  the  usual  signs  of  gastritis,  including 
a  considerable  secretion  of  mucus  from  the  stomach  itself  as 
shown  by  the  microscopic  examination.  There  may  or  not  be 
also  gastric  ulcer  present  which,  when  it  thus  coexists,  may 
probably  be  either  a  result  or  accidental  complication,  though 
according  to  the  opinions  recently  expressed  by  Ewald  and 


5IO  THE    GASTRO-INTESTINAL    CLINIC 

others,  it  is  often  the  cause  of  the  h^^perchlorhydria.  Even  a 
moderate  percentage  of  free  HCl — 0.05  to  o.i — if  persistent 
and  associated  with  a  profuse  secretion  of  mucus  in  the 
stomach,  as  well  as  the  presence  in  the  wash  water  of  de- 
generated cylindric  cells,  and  with  the  symptoms  above 
described,  would  warrant  the  diagnosis  of  chronic  acid  gas- 
tritis, since  in  the  other  forms  of  gastric  catarrh  the  proportion 
of  free  HCl  is  always  much  below  the  normal. 

JJ'Jiat  constitutes  a  normal  HCl  secretion  is  a  mooted  ques- 
tion, and  I  find  myself  differing  from  the  opinions  of  many 
other  gastrologists  in  this  particular.  It  may  be  as  well  to 
give  here  as  anywhere  else  my  reasons  for  believing  that  the 
figures  above  mentioned  are  substantially  correct,  notwith- 
standing the  fact  that  a  considerably  higher  maximum  for 
the  normal  range  is  generally  accepted : 

I.  It  is  well  known  that  intestinal  digestion  progresses  best 
in  an  alkaline,  neutral,  or  only  slightly  acid  medium,  and  also 
that  when  any  surplus  of  uncombined  gastric  juice  meets  the 
alkaline  pancreatic  and  intestinal  juices  and  the  bile  in  the 
duodenum,  the  former  is  simply  neutralized  and  destroyed  by 
the  latter  fluids  with  a  corresponding  loss  in  their  activity. 
Therefore,  since  Nature  is  not  wont  to  provide  under  normal 
conditions  for  such  wastefulness,  it  might  well  be  assumed 
a  priori  that  it  is  not  normal  for  any  considerable  excess  of 
HCl,  pepsin,  etc.,  to  be  left  over  at  the  end  of  gastric  digestion 
to  pass  on  into  the  duodenum  and  derange  digestion  there. 
2.  Observation  of  many  hundreds  of  cases  in  my  practice  fully 
confirms  a  posteriori  the  foregoing  a  priori  considerations. 
The  most  marked  symptoms  of  an  excessive  secretion  of  HCl, 
according  to  the  authorities,  are  a  burning  pain  or  at  least  a 
discomfort  in  the  stomach  toward  the  height  of  digestion, 
constipation  and  disturbed  sleep — insomnia — this  last  symptom 
having  been  frecjuently  noted  and  emphasized  especially  by  me. 
Xow  it  is  an  almost  uniform  experience  with  me  to  see 
patients  suffering  with  some  one  or  all  of  these  symptoms  while 
the  percentage  of  HCl  in  their  gastric  juice  is  between  0.070 


CHRONIC    STHENIC    GASTRITIS  5II 

and  o.ioo,  corresponding  to  the  titration  figures  20  to  30,  and 
then,  upon  reducing-  these  by  medication  or  otherwise  to 
the  minimum  above  mentioned,  the  symptoms  almost  in- 
variably disappear.  The  majority  of  patients  having  more 
than  0.070  per  cent,  of  HCl  have  complained  of  one  or  more 
of  the  above  symptoms  and  among  those  having  o.  100  per  cent, 
or  a  greater  percentage  of  HCl,  it  has  been  quite  exceptional 
not  to  find  all  three  symptoms  present.  These  reasons  would 
seem  to  prove  beyond  question  that  the  figures  generally  stated 
as  representing  the  normal  maximum  proportion  of  HCl  are 
altogether  too  high. 

The  Diagnosis  from  Ulcer. — The  diagnosis  of  sthenic  gas- 
tritis in  its  simple  form  from  the  same  complicated  with  round 
ulcer  is  not  always  possible,  since  the  latter  may  exist  without 
its  usual  typical  symptoms.  In  the  latter  case,  however,  you 
would  generally  find  a  markedly  abnormal  sensitiveness  to 
pressure  somewhere  over  that  portion  of  the  stomach  which 
extends  below  the  ribs,  most  frequently  in  the  middle  line  and 
near  the  sternum,  as  well  as  over  a  small  spot  to  the  left  of  the 
spine  near  the  origin  of  the  eleventh  or  twelfth  rib.  There 
should  be  signs  at  times  also  of  gastric  hemorrhage  (blood  in 
vomit  or  stools)  and  the  symptom  of  pain  aggravated  ahvays 
by  food,  especially  when  in  a  solid  form  and  still  more  if  very 
coarse;  but  these  may  be  wanting. 

In  uncomplicated  acid  gastric  catarrh,  without  ulcer,  vomit- 
ing is  not  common  except  in  the  worst  cases,  and  there  is  never 
hematemesis ;  the  pain  is  generally  relieved  by  taking  bland 
forms  of  albuminous  food,  such  as  milk  or  soft-boiled  eggs, 
and  often  also  by  the  ingestion  of  meat  or  even  bread,  while 
no  foods  afford  any  relief  to  the  pains  of  ulcers,  and  the  coarser 
aliments  nearly  always  aggravate  such  pains  at  once. 
Furthermore,  the  pain  of  acid  gastric  catarrh  may  be  almost 
certainly  and  immediately  relieved  by  full  doses  of  alkalies,  but 
not  so,  as  a  rule,  that  of  gastric  ulcer,  whether  accompanied  or 
not  by  acid  gastritis,  at  least  not  at  once  and  rarely  ever  so 
completely. 


512  THE    GASTRO-INTESTINAL    CLINIC 

It  would  be  a  great  achievement  if,  by  means  of  ever  so 
elaborate  urinary  analyses,  we  could  certainly  determine 
whether  the  stomach  glands  were  secreting  a  normal  propor- 
tion of  HCl,  or  whether  any  departure  from  the  normal  in  this 
respect  was  in  the  direction  of  excess  or  deficiency.  Many 
able  men  have  experimented  in  this  field  and  Boas,  in  his 
"  Magenkrankheiten,"  has  discussed  the  results  somewhat 
fully.  These  have  not  been  very  satisfactory.  I  have  made 
a  number  of  experiments  in  the  same  line,  and  my  results  were 
contradictory.  It  is  possible,  however,  that  eventually  methods 
will  be  perfected  by  which  approximately  accurate  conclusions 
as  to  the  gastric  secretion  may  be  reached  in  this  way.  (See 
Lecture  XI.') 

Microscopic  Help. — Repeated  analyses  of  the  gastric  contents 
in  connection  with  the  symptoms  will  be  sufficiently  diagnostic, 
as  a  rule ;  but  you  may  often  find  in  the  wash  water  after 
lavage,  fragments  of  the  mucous  membrane  in  which  the 
microscope  will  reveal  proliferation  of  the  border  and  chief 
cells  especially.  In  the  older  cases,  many  of  the  cells  may  be 
seen  to  have  undergone  granular  and  mucoid  degeneration  and 
vacuolation  (Van  Valzah  and  Nisbet).  So  much  importance 
is  placed  upon  the  microscopic  demonstration  of  these  cases 
by  Hemmeter  that  he  advises  snipping  off  a  piece  of  the  gastric 
mucous  membrane  by  an  instrument  devised  for  the  purpose, 
when  a  suitable  specimen  cannot  otherwise  be  obtained, 

'  See  also  in  Lecture  IX.,  page  132,  the  account  of  an  "  External  Method 
of  Testing  for  Gastric  Acidity."  Further  experience  confirms  the  state- 
ments there  made  as  to  its  value.  When  there  is  a  marked  excess  of  HCl 
the  external  test  will  ahvaj^s  give  a  positive  result. 


LECTURE  L 

THE  TREATMENT  OF  CHRONIC  STHENIC 
GASTRITIS  (ACID  GASTRIC  CATARRH) 
AND  OF    HYDROCHLORIC  ACID  EXCESS 

In  its  incipiency  acid  gastric  catarrh  is  curable  enough  when 
the  patient  can  be  fully  controlled,  including  his  diet.     When 
there  exists  merely  an  excessive  secretion  of  the  gastric  juice, 
with  only  a  slight  involvement  of  the  secreting  glands,  a  cor-' 
rection  of  the  faulty  hygiene  upon  which  it  depends,   with, 
and  sometimes  even  without,  a  neutralizing  of  the  abnormal 
amount  of  HCl  present  in  the  stomach  during  digestion,  by 
full  doses  of  alkalies,  will  suffice  to  cure  the  affection  com- 
pletely and  within  a  short  time.     Unfortunately,  it  is  scarcely 
ever  recognized  in  this  stage,  since  it  is  so  common  to  classify 
all  the  less  severe  gastric  symptoms  under  the  vague  name  of 
"  dyspepsia  "  and  dismiss  such  ailing  patients  with  a  routine 
prescription,  given  at  a  venture.     But  the  longer  this  form  of 
gastritis  goes  on,  the  more  does  the  mucous  membrane  of  the 
stomach  become  involved.     When  it  is  fully  established  and 
the  cell-proliferation  has  extensively  developed,  it  is  rare  that 
the  affection  can  be  thoroughly  mastered  under  six  months  or 
a  year,  even  with  the  most  skillful  treatment,  and  with  the 
loyal  and  persevering  co-operation  of  the  patient.     Later  on, 
when,  as  almost  inevitably  happens,  the  intestines  have  become 
involved  in  a  secondary  catarrhal  process  and  nutrition  has  be- 
gun to  suffer  severely,  as  shown  by  emaciation,  an?emia,  loss  of 
strength  and  nerve  tone,  and  deranged  cardiac  action  with 
hepatic  enlargement  or  contraction,  insomnia,  and  often  some 
consequent  disease  of  the  skin,  the  difficulties  in  the  way  of  a 
cure  are  vastly  increased  and  the  result  must  be  much  more 
doubtful. 

513 


514  THE  GASTRO-INTESTINAL   CLINIC 

The  prognosis,  then,  of  chronic  acid  or  sthenic  gastritis,  it 
may»be  said,  is  good  in  the  earher  stages,  when  the  patient 
can  afford,  and  is  wilhng,  to  make  the  necessary  sacrifices.  If 
a  brain-worker,  he  may  have  to  abandon  his  business,  or,  at 
least,  reduce  the  time  devoted  to  it.  He  must  certainly  change 
his  habits  as  to  eating,  drinking,  and  much  smoking  at  least, 
and  probably  will  have  to  reform  unhygienic  habits  in  other 
respects.  Even  advanced  cases,  with  the  help  of  such  sacrifices 
and  of  the  best  possible  treatment  followed  up  for  a  long 
time,  may  be  restored  to  fairly  good  health  in  the  end,  though 
there  are  few  diseases  that  tax  more  severely  the  patience  and 
ability  of  the  physician. 

The  treatment  of  acid  gastritis  and  HCl  excess  (hyper- 
chlorhydria)  is  much  the  same;  and  when  the  former  is  mild 
or  the  latter  is  severe  and  stubborn,  it  must  be  identical.  It 
presupposes,  as  an  absolutely  indispensable  condition,  a  few 
laboratory  appliances  and  the  ability  to  make  a  number  of  the 
chemical  analyses  of  the  stomach  contents  that  have  been  de- 
scribed in  previous  lectures. 

As  the  diagnosis  cannot  be  reached  without  the  aid  of  the 
stomach  tube  and  burette,  so  you  will  find  it  necessary  to  make 
the  c|uantitative  tests  for  free  HCl  and  for  the  total  acidity,  at 
least,  in  order  to  manage  a  case  of  this  disease  with  any  hope 
of  success.  For  the  dose  of  alkali  that  fails  utterly  to  lessen 
the  percentage  of  acidity  in  one  patient,  proving  possibly  so 
small  relatively  as  even  to  stimulate  the  glands  to  a  still  more 
excessive  secretion,  may  within  a  few  days  change,  in  another 
patient,  the  excess  of  HCl  into  a  deficiency.  Not  to  be  able  to 
recognize  this  changed  condition  would  risk  injury  to  the 
more  sensitive  patients  by  continuing  longer  with  unsuitable 
remedies. 

By  far  the  most  important  part  of  the  treatment  is  the  hy- 
gienic. You  must,  first  of  all,  free  the  patient,  so  far  as  pos- 
sible, from  any  existing  mental  overstrain,  great  worries,  or 
sexual  erethism.  These  are  probably  among  the  most  prolific 
causes   of    hyperchlorhydria    or    excessive    secretion    of    HCl 


TREATMENT    OF    CHRONIC    STHENIC    GASTRITIS  515 

which,  when  long  continued,  doubtless  usually  results  in 
chronic  sthenic  gastritis.  According  to  my  experience,  when 
it  is  impossible  to  remove  these  disturbing  influences,  as  un- 
fortunately it  often  is,  the  patients  do  not  get  well. 

Rapid  and  excessive  eating  and  insufficient  mastication  of 
food  are  other  prominent  causes  of  the  disease,  and  must  be 
reformed  altogether  before  there  can  be  any  possibility  of  a 
cure.  Still  other  causes  are  movable  kidney,  and  probably  dis- 
placements of  other  viscera. 

The  diet  is  most  important  in  these  cases.  Authorities 
dififer  widely,  however,  on,  this  point.  Probably  a  majority  of 
them  still  recommend  that  patients  be  fed  mainly  on  the  al- 
buminoid foods,  including,  especially,  meat,  eggs,  and  milk, 
for  the  reason  that  these  neutralize  a  far  larger  proportion  of 
the  acid  than  do  the  starchy  foods,  and  for  the  further  reason 
that  starch  ordinarily  is  imperfectly  digested  in  these  cases, 
thus  leading  to  injurious  fermentation. 

These  would  seem  to  be  weighty  reasons — and  at  first  un- 
answerable ones — ^but  my  own  experience  soon  taught  me  that 
on  a  meat  diet  hyperchlorhydric  patients  were  prone  to  grow 
worse  instead  of  better,  and  various  other  specialists  in  gas- 
tric diseases  record  similar  observations.  Pawlow,  Hemmeter, 
and  others  have  demonstrated  that  meat  in  animals  is  a  power- 
ful excitant  to  the  gastric  glands,  largely  increasing  the 
secretion  of  HCl.  These  observed  facts  would  not  settle  the 
matter  if  it  were  true  that  starchy  food  could  not  be  made  to 
digest  in  such  persons.  But  here  again  experience  is  worth 
more  than  theory,  and  it  has  shown  that  the  most  excssive  acid 
secretion  does  not  preclude-  us  from  giving,  with  certain  pre- 
cautions, a  due  proportion  of  carbohydrates  or  starchy  foods. 
A  physiologic  diet — one  that  will  sustain  nutrition  unim- 
paired for  long  periods — must  include  a  preponderance  of  the 
class  of  foods  to  which  starch  and  sugar  belong,  though  the 
hydrocarbons  or  fats  will  help  to  supply  any  deficiency  of  these. 
On  meat,  fish,  and  eggs,  with  even  milk  added,  but  without 
starch  or  sugar,  an  adult  patient  would  ultimately  suffer  se- 


5l6  THE    GASTRO-INTESTINAL    CLINIC 

rious  impairment  of  health.  There  is  some  sugar  in  milk,  but 
not  enough  to  sustain  nutrition  perfectly. 

You  can  overcome  the  difficulty  by  having  the  starch  partly 
predigested  or  caused  to  undergo  artificially  some  of  the 
chemical  changes  that  finally  transform  it  into  sugar.  This 
is  done  by  heat  in  making  toast  or  zwieback,  and  may  be 
greatly  promoted  and  hastened  in  the  stomach  by  administer- 
ing with  the  starch  some  of  the  various  diastasic  preparations, 
including  the  one  known  as  Taka  Diastase,  which  is  quite 
active.  By  giving  moderate  doses  of  calcined  magnesia  and 
bismuth,  or  of  bicarbonate  of  soda,  directly  after  eating  (or 
in  some  instances  before),  the  excessive  acid  can  be  neutralized, 
and  thus  the  continuation  of  salivary  digestion  in  the  stomach 
be  rendered  possible. 

In  cases  of  hyperchlorhydria,  then,  whether  or  not  there  is 
an  associated  gastritis,  your  proper  course  will  be  to  order  as 
bland,  non-stimulating,  and  easily  digestible  a  diet  as  possible, 
at  the  same  time  taking  care  that  it  is  one  that  will  fully  supply 
the  needs  of  nutrition.  You  will  best  accomplish  this  in  most 
cases  by  letting  milk,  when  it  agrees  in  other  respects,  form  a 
large  part  of  the  aliment,  adding  to  this  eggs,  gluten  prepara- 
tions, macaroni  ~or  spaghetti,  and  toast  or  zwieback,  with  also 
an  abundance  of  butter  or  other  fats,  provided  the  intestinal 
digestion  be  not  seriously  impaired.  The  blander  vegetables 
may  also  be  added,  especially  in  the  form  of  purees,  and  baked 
or  boiled  and  mashed  white  potatoes  often  agree  fairly  well, 
when  eaten  slowly  in  the  early  part  of  a  meal.  String  beans, 
spinach,  or  squash  may  usually  be  safely  allowed,  but  all  the 
starchy  foods  need  to  be  thoroughly  well  masticated  and  in- 
salivated, and  taken  in  the  earlier  part  of  a  meal  before  the 
stomach  contents  have  become  excessively  acid.  Idiosyncrasy 
(which  here  means  usually  intestinal  indigestion)  may  compel 
the  omission,  in  certain  cases,  of  various  articles  which  agree 
perfectly  in  others  apparently  similar.  Cane  sugar  is  apt  to 
increase  fermentation,  but  may  sometimes  be  well  borne.  Fish 
or  meat  may  be  safely  allowed  at  one  of  the  three  daily  meals 


TREATMENT    OF    CHRONIC    STHENIC    GASTRITIS  51/ 

in  all  except  the  most  stubborn  cases,  and  may  need  to  be  taken 
at  two  of  tlie  meals  by  patients  Avho  are  obliged  to  live  in 
hotels  or  boarding  houses.  Without  these  foods  patients  so 
situated  are  often  driven  to  desperate  straits,  since  they  can 
rarely  obtain  enough  of  other  viands  that  are  suited  to  them. 
Beef  juice  or  scraped  beef  is  much  better  for  these  patients  than 
meat  fiber,  for  the  double  reason  that  it  digests  much  more 
rapidly  and  is  less  irritant  to  the  inflamed  mucosa  and  glands. 
Hashing  the  meat  and  removing  the  gristly  portions  is  also 
advisable.  All  the  more  acid  fruits  should  be  forbidden, 
though  the  milder  ones,  such  as  baked  sweet  apples,  white 
grapes  and  bananas,  and,  exceptionally,  fully  ripe  peaches  or 
pears,  and  very  sweet  oranges  may  be  allowed  sparingly. 

The  best  beverages  for  such  patients  are  water  and  milk, 
variously  combined  and  flavored.  They  may  be  pleasantly 
warm  at  meal-time,  but  never  hot  enough  to  be  decidedly  stim- 
ulating. There  is  no  objection  to  the  infusions  of  burnt  grains 
known  as  cereal  coffees,  except  that  the  starch  in  them  cannot 
be  insalivated.  They  are  nourishing  and  innocuous  and  many 
patients  soon  learn  to  like  them  almost  as  well  as  their  ac- 
customed infusions  of  the  real  stimulant  beans.  A  large  use 
of  some  non-stimulating  fluid  is  helpful  in  diluting  the  excess 
of  acid  in  these  cases,  both  during  and  after  meals,  except 
when  the  motility  of  the  stomach  has  become  seriously  im- 
paired, and  even  when  there  has  occurred  some  dilatation  from 
pyloric  spasm,  a  glass  of  plain  water  drunk  during  digestion 
will  often  do  good,  rather  than  harm,  by  lowering  the  acidity 
of  the  gastric  contents  to  the  non-irritating  point.  Observation 
in  a  large  number  of  cases  has  led  me  recently  to  this  view, 
which  is  contrary  to  that  taught  by  some  leading  authors  and 
formerly  held  by  me. 

In  the  stomach  coffee  and  tea,  acting  through  the  nervous 
system,  probably  stimulate  primarily,  but  lower  the  digestion 
secondarily  by  overstimulation.  Moreover,  they  both  increase 
the  amount  of  the  xanthin  bases  in  the  system,  and  many  (per- 
haps I  should  say  most)  of  these  patients  suffer  from  so-called 


5l8  THE   GASTRO-INTESTINAL    CLINIC 

uricacidsemia.  Chocolate  is  better  in  cases  of  excessive  HCl, 
except  ^^>hen  there  is  concomitant  intestinal  indigestion,  and 
then.it  usually  aggravates  the  latter  condition. 

The  spirituous  liquors,  though  not  acid,  stimulate  the  gastric 
glands  in  very  small  doses,  and  act  injuriously,  when  long  con- 
tinued in  any  dose,  upon  the  liver,  which,  in  these  cases,  is 
damaged  soon  enough  anyway  b}'  the  auto-intoxication  result- 
ing especially  from  the  intestinal  complications. 

The  most  important  articles  of  diet  contra-indicated  and  to 
be  forbidden  entirely  are  the  sharper  condiments,  such  as 
pepper,  horse-radish,  mustard,  spices  of  all  kinds,  vinegar, 
garlic,  onions,  and  the  hot  or  stimulating  sauces.  An  exces- 
sive amount  of  salt  is  also  objectionable.  Meat  fiber,  unless 
finely  hashed,  tends  to  overstimulate  all  the  more  decided 
cases  of  hyperchlorhydria,  and  should  be  much  restricted  at 
least.  The  vegetables,  like  peas,  beans,  and  corn,  except  when 
prepared  in  puree  form,  contain  much  tough  and  irritating  in- 
digestible residue  and  do  not  suit  such  cases  well.  Coarse  oat- 
meal with  its  sharp  husks,  and  any  of  the  cereals  when  only 
partly  cooked,  are  likely  to  aggravate.  These  foods  irritate  be- 
cause of  their  physical  properties,  and  also  because  the  starch 
cannot  be  well  insalivated. 

When  one  considers  that  in  most  American  restaurants, 
hotels,  and  boarding-houses,  as  well  as  in  the  majority  of  pri- 
vate households,  the  soups  are  fiery  hot,  the  steaks  and  chops 
prepared  with  butter  and  pepper,  and  the  coarser  cereals  that 
are  almost  universally  furnished,  rarely  more  than  half  cooked, 
is  it  any  wonder  that  an  excessive  secretion  of  HCl,  with  or 
without  gastritis  is  the  most  prevalent  form  of  dyspepsia  in 
this  country,  and  that  it  is,  under  ordinary  conditions,  very 
difficult  to  cure? 

Patients  thus  afflicted  should  not  do  more  than  a  very 
moderate  amount  of  micntal  work,  and,  though  they  need  to  be 
as  much  as  possible  in  the  open  air  and  sunshine,  should  not 
exercise  even  their  muscles  excessively — to  the  point  of  marked 
fatigue.     They  should  be  very  moderate  in  sexual  indulgence 


TREATMENT    OF    CHRONIC    STHENIC    GASTRITIS  519 

and  avoid  entirely  sexual  excitement  which  remains  ungrati- 
hed.  They  should,  above  all  else,  have  an  abundance  of  sleep. 
Cold  or  tepid  sponge  baths  (preferably  with  salt  w^ater),  salt 
rubs,  and  various  other  tonic  hydriatic  procedures  are  helpful. 

A  very  valuable  and,  in  many  cases,  an  indispensable  means 
of  combating  the  sthenic,  as  well  as  the  asthenic,  anacid, 
or  atrophic,  forms  of  chronic  gastritis  is  lavage.  In  most  of 
the  advanced  cases,  and  in  all  of  those  with  dilatation  and 
stagnation,  which  may  result  from  spasmodic  contraction  of 
the  pylorus  in  this  disease,  you  will  need  to  wash  out  the 
stomach  every  day,  or,  at  the  very  least,  every  two  days.  Dis- 
solve two  teaspoonfuls  of  bicarbonate  of  soda  in  each  quart  of 
w^arm  water,  and  have  the  lavage  continued  with  this  solu- 
tion until  the  last  comes  away  clean,  without  even  small  frag- 
ments of  mucus.  When  the  stomach  is  badly  infected  with 
yeast  fungi,  or  other  micro-organisms,  I  have  found  the  solu- 
tion of  one-fourth  to  half  a  teaspoonful  of  alum,  along  with  a 
teaspoonful  of  soda,  in  the  last  quart  of  water  a  helpful 
resource. 

The  lavage,  as  a  rule,  should  be  done  in  the  morning,  at 
least  twenty  to  thirty  minutes,  if  possible,  before  breakfast, 
though  there  is  no  objection  to  washing  out  later  in  the  day, 
provided  a  time  can  be  found  when  the  stomach  is  practically 
empty,  so  as  not  to  involve  the  harmfulness  of  removing  di- 
gested nutriment  almost  ready  for  absorption. 

A  practical  wrinkle  which  I  have  hit  upon,  and  found  very 
useful,  is  to  precede  the  lavage  proper  by  having  the  patient 
drink  two  or  three  glasses  of  the  prepared  solution  (or  if  this 
has  too  bad  a  taste,  of  plain  warm  water),  and  then  assume 
such  different  positions  upon  a  couch  or  a  carpeted  floor  as 
will  bring  the  fluid  into  contact  successively  with  every  part 
of  the  stomach,  meanwhile  taking  deep  inspirations  and 
forcibly  contracting  the  abdominal  muscles  so  as  to  make  the 
contained  water  wash  the  walls  of  the  stomach.  For  ex- 
ample, the  patient  should  do  this  at  first  while  lying  on  the 
back,  then  on  either  side,  on  the  face,  and,  finally,  in  the  knee- 


520  THE    GASTRO-INTESTINAL    CLINIC 

chest  position.  These  movements  in  such  positions,  kept  up 
for  three  to  five  minutes  in  all,  will  enable  the  stomach  to  be 
washed  out  afterward  completely  in  one-third  the  usual  time. 

Intragastric  Electricity. — You  need  to  be  fully  informed  as 
to  another  valuable  measure,  which  is  especially  adapted  to 
those  serious  cases  of  chronic  sthenic  gastritis  which  have  be- 
come complicated  by  dilatation  of  the  stomach  with  delayed 
emptying  of  its  contents  and  all  the  dismal  train  of  troubles 
which  follow.  It  is  intragastric  electricity.  By  means  of  my 
modification  of  the  intragastric  electrodes  previously  in  use,  an 
illustration  of  which  is  shown  on  p.  324,  it  is  possible  for  any 
physician  to  treat  in  this  way  the  most  delicate  patients,  in- 
cluding some  of  those  who  cannot  retain  in  position  the  ordi- 
nary stomach  tube  long  enough  to  admit  of  a  complete  lavage. 
This  is  owing  to  the  fact  that  the  cord  carrying  the  current  is 
very  small,  perfectly  insulated,  and  covered  besides  by  thin 
rubber,  while  at  the  same  time  the  lower  end  is  so  stiffened  as 
to  facilitate  its  introduction.  The  end-piece  is  also  so  im- 
proved in  form  as  to  be  easily  swallowed,  and,  what  is  equally 
important,  may  be  withdrawn  without  difficulty.  ( See  cut  No. 
50,  on  p.  324,  and  also  Lecture  XXX.  on  Intragastric  Elec- 
tricity.) But  electricity  will  fail  and  may  even  do  harm  when 
ulcer  is  present  in  either  the  stomach  or  duodenum. 

To  carry  out  this  special  treatment,  connect  one  pole  of  a 
good,  high-tension  faradic  battery  (one  of  Kidder's  latest  has 
served  me  well)  with  a  well-wetted  pad,  about  4x6  inches, 
which  is  to  be  placed  over  the  epigastrium,  or  dorsal  spine, 
against  the  bare  skin.  The  patient  then,  while  sitting,  drinks 
a  full  goblet  of  water,  swallows  the  intragastric  electrode,  and 
lies  down  on  the  back  on  a  comfortable  couch  or  gynecologic 
chair.  The  other  pole  of  the  battery  is  now  connected  with  the 
cord  attached  to  the  electrode  and  the  current  turned  on  gradu- 
ally. No  unpleasant  sensation  should  be  experienced.  For  the 
cases  with  a  large  excess  of  HCl,  the  coil  with  the  finest  and 
longest  wire  (not  less  than  3000  feet  of  a  No.  36  wire)  should 
be  used.     A  current  as  strong  as  can  be  borne  easily  may  be 


TREATMENT   OF   CTIROXIC   STHENIC  GASTRITIS  52 1 

used  for  five  to  eight  minutes  on  alternate  days.  The  vibrator 
or  interrupter,  too,  should  work  smoothly,  and  be  capable  of 
such  rapid  interruptions  as  to  produce  a  uniform  musical  sound. 
Such  treatments  are  often  rapidly  effective,  in  the  absence  of 
ulcer,  not  only  in  lessening  the  excessive  secretion,  but  also  in 
curing  the  catarrhal  process  and  strengthening  and  contracting 
the  dilated  stomach,  but  should  not,  as  a  rule,  be  persevered 
with  for  more  than  a  month  at  a  time  without  intermitting 
them  for  a  week  or  two.  'My  later  experience  proves  that  a 
mild  current  will  often  accomplish  better  results  than  stronger 

ones  in  these  cases. 

Other  Methods  of  Applying  Electricity. — The  galvanic 
current  used  in  the  same  way,  with  the  positive  pole  inside,  is 
sometimes  more  effective  in  controlling  gastric  pain.  The  ordi- 
nary faradic  coils,  with  short,  coarse  wires,  are  more  stimu- 
lating and  suit  better  in  deficient  secretion.  Wdien  for  any 
reason  electricity  cannot  be  applied  directly  to  the  inside  of  the 
stomach,  by  the  method  just  described,  something  may  be  ac- 
complished by  external  applications  of  the  same.  Despite 
claims  to  the  contrary,  my  belief  is  that  strong  currents  can 
be  made  to  penetrate  the  abdominal  walls  sufficiently  to  enable 
both  the  muscular  and  glandular  structures  of  the  stomach  to 
be  affected  favorably,  though  probably  in  only  slight  degree 
directly.  At  all  events,  with  a  large  pad  over  the  epigastric 
region,  and  a  small  electrode  moved  slowly  upward  and  down- 
ward over  the  spine,  the  nerve  centers  and  ner\'es  supplying  the 
digestive  organs  can  be  influenced  in  a  helpful  way.  I  gener- 
ally use  3  to  10  ma.  of  galvanism  in  this  way,  with  positive  to 
the  spine ;  or  20  to  30  ma.  may  be  applied  through  the  stomach 
from  side  to  side.  With  the  positive  pole  in  the  form  of  a  very 
small  electrode,  i  to  3  ma.  may  also  be  passed  through  the 
pneumogastric  nerves  on  the  sides  of  the  neck  (under  the  edge 
of  the  sternocleido-mastoid  muscle)  with  good  results  in  most 
of  these  cases.  The  negative  pole  should  be  over  the  epigastric 
region  as  before.  The  seances  should  be  from  five  to  eight 
minutes  every  other  day,  or  even  every  day  at  first.     Only  the 


522  THE    GASTRO-INTESTINAL    CLINIC 

very  small  doses  mentioned  are  helpful  when  thus  applied  to  the 
neck. 

General  massage,  avoiding  the  abdominal  region,  except  for 
the  lightest  surface  rubbing,  is  an  adjuvant  of  value,  especially 
in  the  worst  cases  in  which  active  exercise  is  not  practicable. 

The  Medicinal  Treatment. — The  use  of  drugs  in  this  disease 
requires  much  care  and  discretion.  The  patients  are  usually 
the  better  for  nerve  tonics,  if  given  through  any  other  avenue 
than  the  stomach,  and  will  often  require  temporarily  anti-spas- 
modics  or  even  sedatives  and  analgesics.  But  alkalies  must 
play  the  largest  role  in  the  medicinal  treatment.  Calcined 
magnesia  has  far  greater  acid-neutralizing  power  than  soda 
and  most  other  alkaline  drugs,  and  is  the  preferable  remedy, 
especially  when,  as  usual,  there  is  associated  constipation. 
The  dose  required  to  neutralize  the  excess  of  acid,  and  gradu- 
ally to  lessen  its  secretion  may  be  anywhere  from  lo  to  30 
grains  (or  even  more)  three  times  a  day,  an  hour  after  meals. 
In  very  severe  cases  it  is  best  to  give  a  dose  of  alkali,  also 
just  before  the  meals,  so  as  to  prevent  interference  with  starch 
digestion. 

When  the  larger  amounts  of  magnesia  are  required,  and  in 
other  cases  when  there  is  no  constipation,  it  is  necessary  to 
combine  5  to  10  grains  of  bismuth  with  each  dose.  It  is,  too, 
often  advisable  to  replace  a  part  of  the  magnesia  b}^  a 
portion  of  sodium  citrate,  which  is  also  an  effective  alkali. 
The  following  is  a  good  combination  for  such  cases  : 

I^     Magnesise  ust£e 3i — 3  iv 

Sodii  citrat 3  ii—  3  ii 

Bism.  subnitrat 3  i —  3  ii 

M.  et  ft.  Chart  No.  XII. 

Sig.  :  One  mixed  with  a  wineglassful  of  milk  or 
water  an  hour  after  each  meal. 

In  particularly  stubborn  cases  (and  plenty  of  such  will  be 
met  with),  the  addition  to  the  above  prescription  of  i  to  2 
grains  of  pulverized  extract  of  belladonna,  or  1-20  grain  of 
atropine,  will  render  it  more  effective,  though  in  that  case,  as 


TREATMENT    OF    CHRONIC    STHENIC    GASTRITIS  523 

these  drugs  powerfully  lessen  the  secretion  of  the  saliva  as 
well  as  of  the  gastric  juice,  it  will  be  well  to  administer  with 
each  meal  a  dose  of  some  good  preparation  of  diastase.  Atro- 
pine usually  succeeds  better  in  simple  hyperchlorhydria  than 
in  acid  gastritis,  and  should  never  be  pushed  long. 

The  following  prescription,  recommended  by  Dr.  Stockton 
of  Buffalo,  has  been  largely  used  for  excessive  HCl  secretion 
by  him,  and  by  Dr.  Allen  A.  Jones  of  the  same  city : 

I^     Cerii   oxalat 3  iv 

Bism.  subcarb 3  viii 

Magnes.  carb.  levis. §  ii 

»  M.     Sig.      One-fourth  to   a   heaping  teaspoonful   in 

water  two  hours  after  each  meal. 

When  the  bowels  are  inclined  to  looseness,  and  the  mag- 
nesia cannot  be  made  to  agree,  the  sodium  bicarbonate  may  be 
used  instead.  But,  in  that  event,  do  not  make  the  mistake  of  ad- 
ministering it  in  too  small  doses,  which  would  aggravate  the 
disease.  I  have  often  seen  even  half-teaspoonful  doses  of  soda 
followed  at  first  by  an  increase  of  the  hyperchlorhydria.  In  the 
severe  cases  it  is  safest  to  give  the  remedy  in  teaspoonful 
doses  three  times  a  day,  and  even  then  it  may  fail.  I  have 
seen  some  such  combination  of  magnesia  and  bismuth  as  those 
above  given  succeed  promptly,  when  soda  in  the  fullest  doses 
had  only  aggravated  the  disease,  and  vice  versa.  There  should 
be  a  cjuantitative  test  of  the  stomach  contents  at  least  every 
week,  during  any  such  course  of  treatment,  to  ascertain  the 
result,  and  avoid  going  too  far.  These  alkaline  remedies 
may  be  repeated  safely  as  often  as  may  be  necessary  to  con- 
trol any  existing  burning  pain,  or  discomfort  due  to  the  ex- 
cessive HCl. 

In  cases  in  which  the  alkalies  are  not  well  borne,  I  have  seen 
the  following  prescription  occasionally  succeed  : 

i^    Ext.  belladonnse gr.  i — gr.  ii 

Ext.  yerbae  santae 3i    ■ 

M.  et.  ft.  mass,  in  pil. ,  No.  XVI.  dividend. 
Sig.:     One  after  each  meal. 


524  THE    GASTRO-INTESTINAL    CLINIC 

In  other  stubborn  cases  in  which  alkahes  do  not  act  well, 
large  (toses  of  bismuth,  such  as  are  suitable  for  gastric  ulcer, 
according  to  Fleiner's  method,  may  effect  good  results.  For 
example : 

I^     Bismuthi  subnit 3  vi —  §  i 

Ft.  chart  No.  XII. 

Sig. ;     One  mixed  with  milk  or  water  half  an  hour  be- 
fore each  meal. 

Possibly  in  the  exceptional  cases,  in  which  this  prescription 
proves  successful,  there  are  latent  ulcers  which  keep  up  the  Ir- 
ritation of  the  glands. 

Nitrate  of  silver  in  doses  of  1-8  to  1-4  grain  is  sometimes 
a  very  useful  remedy.  It  may  be  combined  effectively  as 
follows : 

I^    Argent,  nitrat gr.  ii — gr.  iii 

Ext.  bellad gr.  i 

Bism.  subnit 3  ii 

M.  et.  ft.  mass,  in  capsulae,  No.  XVI.  dividend. 
Sig.:     One  after  each  meal. 

This  combination  is  adapted  best  to  cases  in  which  the 
bowels  are  too  loose,  or  may  be  given  additionally  to  correct 
the  overlaxative  effect  of  the  treatment  by  magnesia. 

In  stubborn  cases  frequent  changes  of  the  remedy  are  neces- 
sary. Musser  recommends  the  largest  practicable  doses  of  nux 
vomica  as  very  efficient,  and  Goodman  found  that  hydrogen 
peroxide  would  very  markedly  lessen  the  secretion  of  HCl. 

Another  Useful  method  of  treating  the  disease  under  con- 
sideration is  by  spraying  the  inside  of  the  stomach  with  a  o.  i  to 
0.2  per  cent,  solution  of  nitrate  of  silver,  after  first  washing 
out  the  viscus. 

In  most  cases  of  acid  gastric  catarrh,  when  the  patient  can 
rest,  eat,  and  drink  rationally,  and  reform  all  hygienic  faults, 
it  is  not  so  difficult  to  remove  all  symptoms,  to  stop  virtually 
entirely  the  excessive  secretion  of  mucus,  and  to  bring  the  HCl 
within  normal  limits,  as  it  is  to  maintain  this  improved  condi- 
tion.    The  trouble  is  that  the  patient,  while  often  rapidly  re- 


TREATMENT    OF    CHRONIC    STHENIC    GASTRITIS  52$ 

lieved  of  all  that  he  complained  of,  will  rarely  continue  treat- 
ment till  the  physician  finds  by  his  tests,  chemical  and  micro- 
scopic, that  the  disease  has  been  really  cured.  A  low-grade 
inflammation  of  the  gastric  mucous  membrane  persists,  and 
when  treatment  with  the  careful  diet,  and  attention  to  hy- 
gienic requirements  otherwise  are  abandoned,  the  symptoms 
soon  return. 

The  only  safe  plan  is  to  insist  upon  careful  living,  with  some 
mild  treatment,  until  the  disease  can  be  shown  to  be  well ;  and, 
even  then,  to  warn  the  patient  that  only  by  persevering  with  a 
reasonable  amount  of  care  can  he  continue  well.* 

The  Treatment  of  Hyperchlorhydria  will  be  referred  to 
again'  in  Lecture  LI.,  but  differs  in  no  wise  from  that  de- 
scribed above,  when  it  is  severe,  or  inclines  to  be  persistent, 
and,  indeed,  I  believe  with  Hayem,  that  in  such  severe  cases  at 
least,  there  probably  exists  a  real  proliferation  of  the  secret- 
ins: structures.  But  in  the  milder  cases,  much  less  need  be 
done  than  is  required  for  well-marked  sthenic  gastritis.  Com- 
plete rest  of  both  mind  and  body,  or  at  least  a  lessened  demand 
upon  the  nervous  energies  in  all  ways,  with  a  carefully  regu- 
lated diet,  suffices  usually  to  effect  a  recovery  in  such  cases 
within  a  few  weeks.  When  these  hygenic  measures  alone  fail, 
toning  up  the  nervous  system  by  means  of  electricity,  and 
hydriatic  applications,  with  or  without  the  administration  of 
moderate  doses  of  alkalies  two  hours  after  meals,  and  perhaps 
also  a  small  dose  of  bromide  of  sodium  combined  with  a  little 
hyoscyamus  or  belladonna  at  bedtime,  will  nearly  always 
promptly  succeed. 

I  A  large  experience  with  chronic  acid  gastric  catarrh  convinces  me  that 
the  importance  of  this  disease  and  of  all  the  more  stubborn  forms  of  hy- 
perchlorhydria is  greatly  underestimated  by  the  profession  generally. 
In  such  cases  when  alkalies,  sedatives,  and  intragastric  electricity  have  all 
failed,  the  treatment  for  gastric  ulcer  ought  to  be  insisted  upon,  especially 
its  main  features,  rest  in  bed,  rectal  feeding,  etc. 


LECTURE  LI 

HYPERCHLORHYDRIA   AND 
HYPERSECRETION 

In  discussing  chronic  sthenic  gastritis  in  Lectures  XLIX.  and 
L.,  I  touched  incidentally  upon  simple  hyperchlorhydria,  a  con- 
dition which  is  supposed  by  most  authorities  to  be  neurosal 
merely.  It  is  often  impracticable  for  even  an  expert  to  diag- 
nosticate between  a  case  of  marked  hyperchlorhydria  and  in- 
cipient or  mild  acid  gastritis,  and  the  treatment  of  the  two 
affections  is  the  same  precisely,  except  that  lavage,  which  is 
probably  indispensable  in  advanced  cases  of  the  inflammatory 
affection,  is  not  necessary  in  the  simple  neurosis. 

For  the  sake,  however,  of  completeness  in  this  series,  and 
also  because  gastrox)^nsis  and  Reichmann's  disease,  forms  of 
hypersecretion  of  the  gastric  juice,  are  important,  I  have  de- 
cided to  devote  a  brief  separate  lecture  to  this  group  of  affec- 
tions. 

Keeping  in  mind  the  essentially  practical  character  sought  to 
be  given  to  the  instruction  herein  imparted,  I  shall  avoid  dis- 
puted questions  and  the  citation  of  many  authorities,  even  at 
the  risk  of  being  considered  dogmatic;  but  anyone  desirous  of 
delving  more  deeply  into  these  subjects  will  naturally  obtain 
some  one  of  the  numerous  complete  treatises  upon  them  now 
accessible,  even  in  English. 

It  is  my  own  opinion,  that  there  rarely  occurs  a  long  con- 
tinuance of  an  excessive  secretion  of  the  gastric  juice  or  of  its 
most  active  ingredient,  free  HCl,  from  whatever  cause,  with- 
out some  proliferation  of  the  secretory  glands. 

526 


EXCESSIVE  SECRETION  OF  THE  GASTRIC  JUICE 


527 


Symptomatology.- — Simple  hyperchlorh3'dria  presents  the 
symptoms  already  described  under  Chronic  Sthenic  Gas- 
tritis in  Lecture  XLIX.  If  they  have  not  lasted  long,  it 
may  be  inferred  that  they  probably  arise  in  consequence  of  a 
reflex  disturbance  in  some  other  part,  such  as  a  movable  kid- 
ney, hepatic  or  renal  calculus,  or  some  disorder  in  the  nervous 
or  sexual  system,  and  they  are  not  necessarily  a  result  of  a 
sthenic    (acid)    gastritis.     If   they   have   existed    either    per- 


FiG.  71. — Magnesium  phospiiate-crystals  from  stomacli  contents  in  a  case 
of  hyperchlorhydria  and  neurasthenia.  The  same  crystals  were  found 
in  the  urine. 

sistently  or  intermittently  for  years,  or  even  many  months, 
there  may  well  be  a  strong  suspicion  of  cell  proliferation,  and 
it  may  then  be  expected  that  the  disease  will  not  yield  easily 
or  quickly.  The  excessive  secretion  then  may  be  speedily  les- 
sened, often  by  full  doses  of  the  alkalies  or  belladonna,  but  then 
soon  returns  after  the  remedy  has  been  suspended. 


528  THE    GASTRO-INTESTINAL    CLINIC 

In  gastroxynsis,  or  gastrosiiccorrhea  chronica  periodica, 
there  are  sudden  and  severe  attacks  of  nausea,  vomiting,  and 
gastric  pain,  in  which  quantities  of  fluid  mixed  with  mucus, 
and  sometimes  bile,  are  brought  up,  showing  a  large  excess  of 
HCl,  and  accompanied  usually  by  headache,  which  may  be  in- 
tense, and  by  depression  or  prostration.  The  attacks  come  on 
suddenly,  most  frequently  in  the  night,  and  last  one  or  several 
days.  They  recur  at  varying  intervals,  sometimes  as  often  as 
once  a  week,  though  rarely  so  often,  and  sometimes  they  are  a 
year  or  more  apart.  Between  them  the  patient  may  seem  well, 
though  often  a  considerable  excess  of  HCl  will  be  found  in  the 
stomach  during  the  digestive  periods. 

Hyperchlorhydria  is  very  much  more  frequently  encoun- 
tered than  either  of  the  forms  of  hypersecretion.  Gastroxynsis 
is  now  generally  believed  to  be  only  a  symptom,  in  some  cases 
of  tabes  and  in  others  probably  of  pyloric  obstruction  due  to 
ulcer,  excessive  HCl  or  some  one  of  various  other  causes.  It 
is  possible,  too,  that  this  symptom  may  be  only  a  periodical  ex- 
acerbation of  the  continuous  form  of  hypersecretion. 

The  contimious  hypersecretion  or  Reichmann's  disease, 
often  called  also  gastrosiiccorrhea  chronica  continua,  is  exceed- 
ingly rare  as  a  pure  neurosis,  if  ever  such,  most  of  the  cases 
probably  being  the  result  of  peptic  ulcer  and  an  obstructed 
pylorus  with  gastric  dilatation.  The  symptoms  are  those  of 
hyperchlorhydria,  except  that  they  persist  during  the  intervals 
between  the  digestive  periods — -that  is,  not  only  when  there  is 
food  in  the  stomach,  but  also  when  there  is  not.  Considerable 
fluid  containing  the  elements  of  the  gastric  juice,  in  which  the 
proportions  of  free  HCl  and  other  acid  elements  are  generally 
decidedly  excessive — though  not  always — can  be  found  in  the 
stomach  in  the  morning  fasting,  and  not  mixed  with  remains  of 
food,  even  when  the  stomach  has  been  washed  out  thor- 
oughly the  preceding  evening.  Marked  nervousness,  with  usu- 
ally constipation,  and  most  commonly  insomnia,  are  further 
symptoms  of  importance. 

Differential  Diagnosis — This  must  turn  almost  entirely  upon 


EXCESSIVE  SECRETION  OF  THE  GASTRIC  JUICE  529 

the  chemical  and  microscopic  examinations  of  the  stomach 
contents.  When  an  abnormally  high  percentage  of  HCl  is 
present  during  digestion  only,  and,  besides  an  absence  of  any 
considerable  amount  of  mucus  of  gastric  origin,  there  "is  an 
absence  also  of  cell  elements  coming  from  the  gastric  mucous 
membrane  and  showing  proliferation,  the  case  is  one  of 
hyperchlorhydria,  probably  without  any  gastric  catarrh.  When 
there  are  the  same  findings  at  all  times  of  the  day,  in  the  morn- 
ing fasting  as  well  as  at  other  times,  the  trouble  is  most 
likely  to  be  Reichmann's  disease. 

When  the  symptoms  and  signs  of  HCl  excess  come  on  peri- 
odically, and  with  violence,  yielding  to  treatment  in  a  clay,  or 
in  two  or  three  days,  and  leaving  the  patient  between  times 
well,  except  nervous  symptoms,  or  with  only  a  moderate  hyper- 
chlorhydria, the  trouble  may  be  set  down  as  gastroxynsis. 

The  diagnosis  from  gastric  ulcer  is  not  always  easy.  In- 
deed, it  is  rarely  possible  to  exclude  ulcer  positively  in  any 
case  of  painful  indigestion,  especially  with  an  excessive  or 
normal  percentage  of  HCl.  But  in  most  cases  of  ulcer  there 
are  markedly  sensitive  spots  over  the  epigastric  region — 
usually  near  the  ensiform  process — and  very  often  at  the  left  of 
the  spine  near  the  origin  of  the  eleventh  and  twelfth  ribs. 
Even  moderate  pressure  upon  these  spots  elicits  decided  pain. 
Then  hemorrhage  from  the  stomach,  shown  either  by  the 
vomiting  of  blood,  or  altered  blood,  or  passing  the  same  with 
the  stools  (coflfee-ground  vomit  or  stools),  occurs  at  times  in 
at  least  four-fifths  of  all  cases  of  ulcer,  and  not  in  the  uncom- 
plicated forms  of  excessive  HCl  or  of  hypersecretion.  The 
pain  is  more  severe,  and  longer  lasting  usually  in  ulcer,  and  is 
aggravated,  almost  never  relieved,  by  food,  especially  by  solid 
food. 

Let  me  guard  you  against  one  mistake,  which  is  often  made 
by  good  clinicians,  and  by  some  even  who  consider  themselves 
stomach  specialists — that  is,  relying  upon  Congo  red  paper 
in  testing  for  free  HCl.  Congo  red  is  changed  decidedly  in 
color  to  a  bluish  tint  by  any  kind  of  free  acid,  even  by  organic 


530  THE    GASTRO-INTESTINAL    CLINIC 

acids,  especially  if  present  in  considerable  amount,  though  the 
change  !s  to  a  more  pronounced  blue  in  the  presence  of  free 
HCl.  It  is  wholly  unreliable  except  as  an  evidence  that  some 
form  of  free  acid  is  in  the  stomach  contents.  There  are  other 
almost  equally  convenient  tests  for  HCl,  which  are  always  re- 
liable— especially  the  phloroglucinvanillin  (Giinzburg)  test. 

The  Prognosis  is  good  in  simple  hyperchlorhydria,  but  in 
the  two  forms  of  hypersecretion  it  depends  upon  the  cause — 
good  when  this  can  be  removed.  The  severer  cases  are  always 
stubborn,  and  are  very  liable  to  relapse. 

Treatment. — I  can  add  very  little  to  the  measures  previously 
advised  for  the  major  affection — acid  gastric  catarrh.  In  gas- 
troxynsis  no  food  should  be  given  the  first  day,  and  after  that, 
feeding  should  be  resumed  very  cautiously  and  tentatively  with 
spoonful  doses  of  milk  and  limewater  or  beef  juice,  white  of 
egg  and  such  predigested  aliments  as  Somatose  powder  with 
milk,  or  the  Somatose  biscuits,  Bovinine  (one  or  two  tea- 
spoonfuls  in  a  wineglassful  of  milk  or  water),  Plasmon,  and 
Eskay's  Food  with  milk.  After  a  day  or  two  of  small  feed- 
ings with  one  or  more  of  these  every  two  hours,  the  diet  may 
be  gradually  enlarged  to  that  prescribed  in  Lecture  L.  for 
chronic  sthenic  gastritis,  which  is  the  same  as  that  suitable 
for  simple  hyperchlorhydria,  as  well  as  for  Reichmann's 
disease. 

During  an  attack  of  gastroxynsis  the  patient  should  be  kept 
in  bed,  and  lavage  with  an  alkaline  solution  will  help  most. 
Anodynes  are  often  required.  A  partial  rest  treatment  is  often 
helpful  during  the  first  month  or  so  of  the  management  of 
other  severe  cases  of  hypersecretion.  Rest  on  the  back  a  part 
of  every  day,  with  massage,  except  over  the  abdomen,  Swedish 
movements  and  electricity  are  often  very  advantageous,  bat  a 
complete  rest  from  mental  occupation  and  from  sexual  excite- 
ment is  still  more  important.  Eisner  insists  that  patients  with 
hypersecretion  need  the  treatment  for  ulcer.  This  is  true  of 
any  refractory  case  of  overacting  gastric  glands. 

In   simple   hyperchlorhydria   lavage   and    intragastric   elec- 


EXCESSIVE  SECRETION   OF  THE  GASTRIC  JUICE  53 1 

tricily  are  not  often  necessary,  but  in  Reichmann's  disease  they 
may  both  prove  very  useful,  provided  ulcer  can  be  excluded. 
(See  Lecture  L.,  on  the  Treatment  of  Chronic  Sthenic  Gastritis 
and  HCl  Excess.) 

The  medicinal  remedies  advised  for  acid  gastric  catarrh  act 
equally  well  usually  in  the  nervous  forms  of  excessive  HCl 
and  in  hypersecretion.  In  Reichmann's  disease,  it  is  important 
above  all  to  ascertain  and  treat  the  cause.  Atropine  in  fairly 
full  doses  often  needs  to  be  administered,  but  it  should  not  be 
forgotten  that  when  the  remedy  is  carried  to  the  point  of  dry- 
ing the  mouth,  it  is  very  desirable  to  give  some  active  diastasic 
preparation  with  or  near  the  meals — preferably  the  Taka 
Diastase.  Nitrate  of  silver  is  another  remedy  which  should 
be  remembered,  both  for  its  tonic  action  on  the  central  nervous 
system,  and  for  its  astringent,  antiseptic,  and  locally  sedative 
action  on  the  gastric  mucous  membrane.  Hydrogen  peroxide 
is  also  both  sedative  and  antiseptic. 

Alkalies  and  alkaline  spring  waters,  especially  Carlsbad  and 
Bedford,  can  be  employed  helpfully,  if  carefully  watched  and 
stopped  in  time.  Hyperacidity  is  not  the  same  as  hydrochloric 
acid  excess.  Before  leaving  this  subject,  I  desire  to  impress 
upon  you  a  few  words  of  caution : 

A  relic  of  the  old  days,  when  all  of  us  had  to  guess  at  the 
probable  character  of  the  contents  of  our  patients'  stomachs,  is 
the  ambiguous  and  very  mischievous  word  hyperacidity.  The 
term  acid  dyspepsia  has  also  come  down  to  us  from  the  same 
hazy  prescientific  period.  Some  writers,  unfortunately,  still 
designate  indigestion  with  HCl  excess  as  acid  dyspepsia,  and 
refer  to  hyperchlorhydria  as  hyperacidity.  This  is  a  vague- 
ness which  has  caused  much  very  bad  therapeutics. 

An  excess  of  organic  acids,  such  as  lactic,  acetic,  butyric, 
etc.,  often  produces  a  marked  and  painful  acidity  of  the  stom- 
ach contents  with  very  injurious  results  to  the  intestinal  di- 
gestion as  well  as  to  the  intestinal  mucous  membrane  and  the 
nervous  system.  Even  spasm  of  the  pylorus  and  dilatation 
may  probably  be  results  of  this  form  of  acidity.     Such  a  hyper- 


532  THE    GASTRO-INTESTINAL    CLINIC 

acidity  is  caused  by  an  opposite  condition  to  that  found  in 
hydrocWoric  acid  excess — that  is  a  condition  of  debihty,  or 
more  or  less  complete  atrophy  of  the  gastric  glands  which  re- 
sults in  a  deficiency  or  even  total  absence  of  secretion  of  the 
gastric  juice.  To  treat  this  markedly  asthenic  condition  by 
alkalies  and  other  remedies  designed  to  diminish  the  activity 
of  the  glandular  structures  of  the  stomach  would  naturally 
lead  in  the  end  to  a  disastrous  aggravation  of  the  disease  and 
all  its  symptoms ;  yet  this  is  frequently  done  by  men  who  do 
not  analyze  the  gastric  contents  of  their  patients,  on  the  suppo- 
sition that  the  vomiting  or  gulping  up  of  intensely  sour  ingesta 
signifies  hyperacidity,  or  acid  dyspepsia,  and  that  this  always 
demands  an  alkaline  treatment. 

In  such  cases,  when  the  vomited  ingesta  are  sour  from  an 
excess  of  organic  acids  with  absence  or  a  deficiency  of  HCl 
and  pepsin,  an  exactly  contrary  line  of  treatment  is  usually  re- 
quired— to  wit,  the  administration  of  these  deficient  elements 
of  the  gastric  juice  as  medicines,  together  with  roborant  treat- 
ment generally. 

Von  Noorden'  has  brought  forward  a  new  theory  as  to  the 
causation  of  the  various  forms  of  hyperchlorhydria.  He  con- 
siders the  excessive  secretion  of  HCl.  when  not  secondary  to 
organic  disease,  to  be  a  direct  result  of  constipation — intestinal 
paresis.  He  holds  that  it  can  be  cured  by  the  saline  waters, 
such  as  those  of  Homburg  and  Kissengen,  and  an  abundant 
coarse  diet — a  regimen  similar  to  that  employed  by  him  in 
colica  mucosa  which  is  described  at  length  in  Lecture  LXXHI. 

'  Arch,  de  med.  No.  34,  1905.     Gaz.  med.  Beige,  January  4,  1906, 


LECTURE  LII 
ROUND  ULCER  OF  THE  STOMACH 

Ulcer  of  the  stomach,  called  also  round  or  peptic  ulcer,  is 
often  latent,  running  its  course  either  entirely  without  symp- 
toms, or  with  only  such  as  are  ordinarily  referred  to  dyspep- 
sia. Pain,  and  the  loss  of  blood,  either  by  vomiting  or  by  way 
of  the  bowels,  though  present  in  a  large  proportion  of  cases, 
may  both  be  absent.  In  consequence  of  this  frequent  latency  of 
the  disease,  and  of  the  fact  that  it  has  not  yet  become  customary 
to  make  thorough  examinations  in  cases  presenting  merely  the 
symptoms  of  indigestion,  gastric  ulcer  often  runs  its  course 
unsuspected.  It  may  then  terminate  in  a  spontaneous  cure  (as 
in  numerous  reported  cases  in  which,  after  death,  the  scars  of 
healed  ulcers  have  been  found),  or  in  sudden  death  from 
hemorrhage  or  perforation. 

Every  practitioner  of  the  healing  art  needs  to  be  very  fa- 
miliar with  the  symptoms  and  signs  of  gastric  ulcer,  because 
of  its  insidiousness  and  the  grave  dangers  attending  a  failure 
to  recognize  and  treat  it  in  time ;  and  since  it  so  frequently  mas- 
querades in  the  garb  of  a  more  or  less  severe  dyspepsia,  you 
should  look  upon  chronic  indigestion  not  as  a  trifling  matter, 
but  always  as  a  condition  demanding  a  careful  inquiry,  and 
thorough  physical  examination  at  least.  When  the  results  of 
these,  taken  in  connection  with  the  symptoms,  point  toward  the 
probability  of  ulcer,  you  will  do  well  to  give  your  patient  the 
benefit  of  any  doubt  by  instituting  at  once  the  very  hopeful 
treatment  hereafter  to  be  described. 

-Etiology. — It  has  not  yet  been  decided  positively  what 
causes  ulcer  of  the  stomach,  but  it  probably  results  from  the 
corroding  action  of  a  gastric  juice  excessively  strong  in  HCl, 

533 


534  THE    GASTRO-IXTESTINAL    CLINIC 

under  certain  predisposing  conditions,  such  as  chlorosis,  and 
others  not  fully  understood.  The  causes  of  hyperchlorh3-dria 
are,  therefore,  probably  prominent  among  the  causes  of  ulcer. 
The  disease  is  said  to  be  almost  unknown  among  simple  peas- 
ant populations  that  subsist  upon  vegetables  mainly,  or  other 
plain,  unstimulating  food,  and  live  almost  entirely  in  the 
open  air. 

The  Incidence  of  Ulcer  as  to  Sex  and  Age. — Alost  authori- 
ties agree  that  gastric  ulcer  is  more  frequent  among  women 
than  men,  though  a  few  report  a  contrary  experience.  Chlo- 
rosis, which  is  very  often  accompanied  by  hyperchlorhydria, 
is  rarely  seen,  except  in  women,  and  movable  kidney,  which 
certainly  predisposes  strongly  to  HCl  excess,  is  almost 
monopolized  by  women;  and  HCl  excess  is  at  least  a  nearly 
constant  accompaniment,  if  not  a  demonstrable  cause,  of 
ulcer.  Even  in  the  cases  in  which  the  ulcer  is  apparently  the 
primary  condition  there  was  probably  a  previous  latent  hyper- 
chlorhydria. The  young  are  more  subject  to  ulcer  of  the 
stomach  than  the  old,  while  the  contrary  is  true  of  cancer; 
three- fourths  of  the  cases  of  ulcer  are  said  to  be  in  persons 
between  the  ages  of  twenty  and  sixty,  and  the  largest  propor- 
tion occurs  between  twenty  and  thirty.  Numerous  cases  in 
children  ha^•e  been  reported.  The  only  really  reliable  statistics 
concerning  gastric  ulcer  are  those  from  the  deadhouse.  These 
show  two  important  facts ; 

1.  Ulcer  of  the  stomach  is  rather  a  frequent  disease,  va- 
rious authors  cited  by  Riegel  having  reported  percentages  of 
bodies  found  with  either  open  ulcers  or  scars  of  healed  ones, 
ranging  from  one  to  twenty.  This  would  indicate  an  average 
of  lo  per  cent.,  which  is  doubtless  too  high;  but  it  is  alto- 
gether probable  that  at  least  5  per  cent,  of  persons  dying  from 
all  causes  either  had  gastric  ulcer  at  death,  or  had  had  it  at 
some  time  before. 

2.  The  numerous  autopsies  made  in  all  parts  of  the  world 
have  proved,  beyond  question,  that  a  large  percentage  of  gas- 
tric ulcers  recover  spontaneously,  since  the  proportion  of  dead 


ROUND    ULCER    OF    THE    STOMACH  535 

bodies  found  with  open  ulcers,  to  those  showing  scars  of 
healed  ulcers  is  scarcely  one  to  two,  and  according  to  some  it 
is  only  one  to  three. 

Pathology. — Gastric  ulcer  is  the  result  of  self-digestion  of 
some  portion  of  the  mucosa  during  life.     How  this  autodiges- 


r 


/ 


^. 


^4    \ !_2i 


Fig.  72. — The  pyloric  end  of  a  stomach,  showing  an  ulcer  on  the  posterior 
wall.  (From  a  preparation  in  the  Museum  University  College. 3  About 
natural  size.  The  ulcer  measures  3/4  by  9/16  inch.  It  is  oval,  with 
deeply-cut  overhanging  margins;  complete  perforation  of  the  coats  of 
the  organ  having  taken  place  so  that  there  is  a  small  cavity  outside  the 
organ.  The  floor  is  formed  by  thickening  omental  or  mesenteric  tissue. 
Bristles  are  placed  in  three  openings,  which  are  erosions  into  large 
arteries,  branches  probably  of  the  coronary  artery.  From  a  young  male 
who  died  from  repeated  hematemesis.  (From  Sidney  Martin's  "Diseases 
of  the  Stomach.") 

tion  takes  place  we  are  not  in  a  position  to  explain,  nor  why. 
Weinland  has  recently  claimed  that  an  antibody  (antipepsin) 
is  normally  present  in  the  gastric  mucosa.  Deficiency  of  tliis, 
from  unknown  causes,  in  any  part,  leaves  it  vulnerable. 
Virchow  suggests  that  thrombosis  or  infarction  of  the  nutrient 
blood-vessels  brings  about  conditions  favorable  for  autodiges- 


536  THE    GASTRO-INTESTINAL    CLINIC 

tion.  This  view  was  long  generally  accepted,  but  it  is  much 
questiAied  now.  A  general  condition  of  ill  health,  and  espe- 
cially ansemia,  seems  to  be  a  frequent  predisposing  factor. 
Gastric  ulcer  is  circular  or  oval,  having  a  punched-out  appear- 
ance, with  the  edges  but  slightly  changed.  It  thus  differs  from 
ulcers  of  inflammatory  origin.  It  is  cone-shaped,  the  ex- 
cavation tapering  by  a  series  of  terraces  towards  the  serous 
layer.  This  form  of  the  ulcer  suggests  its  origin  from  an  in- 
farct, as  the  shape  corresponds  to  the  distribution  of  an  end 
arter3\  The  diameter  of  the  ulcer  varies  from  two  to  six  cm. 
It  may  be  larger  and  possess  serrated  edges.  It  is,  as  a  rule, 
single,  but  may  be  multiple.  Gastric  ulcer  is  essentially 
chronic  in  its  course,  and  heals  generally  by  scar  formation. 
It  may  lead  to  fatal  hemorrhages,  to  perforation,  or  to  ad- 
hesions with  the  neighboring  structures.  The  cicatrix  may 
bring  about  stenosis  of  either  orifice,  especially  of  the  pylorus, 
or  the  hour-glass  form  of  contraction,  which  sometimes  divides 
the  stomach  into  two  almost  separate  pouches. 

The  following,  from  Welch's  article  on  Simple  Ulcer  of  the 
Stomach,  in  volume  ii.  of  "  Pepper's  System  of  Medicine," 
shows  the  relative  frequency  with  which  the  ulcer  affected  the 
d-fferent  parts  of  the  stomach  in  793  cases : 

Lesser  curvature,  28S  (36.3  per  cent.) ;  posterior  wall,  235  (29.6  per 
cent.)  ;  pylorus,  95  (12  percent.)  ;  anterior  wall,  69  (8.7  percent.)  ;  cardia, 
50  (6.3  per  cent.)  ;  fundus,  29  (3.7  per  cent.)  ;  greater  curvature,  27  (3.4 
per  cent.).  , 

Acute  gastric  ulcer  is  usually  small,  punched-out,  with  clean- 
cut  edges  and  smooth  floor.  It  may  be  round  or  oval,  or  a 
mere  fissure,  but  even  from  this  last  a  fatal  hemorrhage  is  said 
to  be  possible.  There  is  no  thickening  and  the  ulcer  may  be 
hard  to  find. 

Symptomatology. — The  three  most  prominent  symptoms  of 
gastric  ulcer  are  pain,  hemorrhage,  and  circumscribed  tender 
spots.  The  pain  is  distinctly  digestive,  coming  on  usually 
shortly  after  the  taking  of  food.  It  is  proportionate  in  degree 
to  the  solidity  or  roughness  and  the  quantity  of  the  food  in- 


ROUND    ULCER    OF    THE    STOMACH  537 

gested,  and,  as  a  rule,  to  which  there  are  some  exceptions,  dis- 
appears when  the  stomach  has  been  emptied  either  by  vomit- 
ing or  in  the  normal  way  by  propulsion  into  the  intestine.  The 
pain  may  be  of  any  degree  of  severity.  It  is  usually  of  a  per- 
sistent burning  or  boring  character,  but  may  be  violent  or  spas- 
modic. It  is  localized  generally  in  the  epigastrium  somewhat 
to  the  left  of  the  middle  line  and  may  radiate  to  the  spine. 
Rarely  the  pain  is  felt  in  the  back  opposite  the  stomach,  and 
not  at  all  in  front.  The  fact  that  it  is  not  felt,  or  only  very 
exceptionally  felt,  when  the  stomach  is  empty,  and  is  either 
absent  or  greatly  less  in  degree  when  only  licjuid  food  has  been 
taken,  is  almost  diagnostic  of  gastric  ulcer,  though  the  pain 
of  hyperchlorhydria  is  sometimes  similar  in  its  manifestations. 
The  latter  pain,  however,  usually  comes  on  later,  not  often 
until  an  hour  or  two  after  eating,  and  is  apt  to  increase  in 
severity  up  to  the  time  when  digestion  is  at  its  height,  and 
taking  more  food,  especially  if  richly  nitrogenous,  or  large 
doses  of  alkaline  drugs,  relieves  it,  while  the  pain  of  ulcer  fol- 
lows often  immediately  upon  the  taking  of  food,  and  the  more 
food  generally  the  greater  the  pain.  It  may  be  nearly  as  se- 
vere at  first  as  later,  or  become  lighter  as  digestion  pro- 
gresses, and  as  the  gastric  contents  are  licjuefied.  But  it  is  to 
be  borne  in  mind  that  ulcer  and  hyperchlorhydria  very  often 
go  together,  and  when  they  do,  the  pain  resulting  from  the 
two  combined  conditions  is  likely  to  increase  up  to  the  acme 
of  digestion  from  one  to  three  hours  after  a  meal,  just  as  in 
cases  of  uncomplicated  hyperacidity. 

The  hemorrhage  may  reveal  itself  either  by  the  vomiting  of 
fresh  red  blood  (sudden  and  severe  hemorrhage),  or  by  dark 
changed  blood  (coffee-grounds  vomit),  or  by  the  passage  of 
tarry  stools  of  altered  blood  (melena).  The  amount  of  blood 
lost  may  be  very  small — the  so-called  "  occult  blood  " — from 
the  erosion  of  minute  vessels,  and  be  recognizable  only  by 
painstaking  examination  of  the  stools ;  or  very  large,  amount- 
ing sometimes  to  eight,  sixteen,  or  even  twenty-four  ounces  at 
one   time.     A  very   copious  hemorrhage    from   the   stomach, 


538  THE    GASTRO-INTESTINAL    CLINIC 

showing  itself  by  both  sudden  and  severe  hematemesis  and 
black  stools  of  altered  blood,  points  to  ulcer  rather  than  to 
cancer  of  the  stomach,  since  in  cancer  large  hemorrhages  are 
unusual.  In  either  disease  the  hemorrhage  may  be  entirely  oc- 
cult. 

In  all  cases  of  suspected  ulcer  or  carcinoma  without  open 
hemorrhage  frequent  tests  of  stomach  contents  or  stools  for 
occult  blood  should  be  made.  In  carcinoma  the  bleeding  is 
apt  to  be  less  marked  than  in  ulcer,  but  more  constant. 

Marked  tenderness  on  pressure  over  a  small  circumscribed 
area  in  the  epigastrium  (as  well  as  often  on  the  left  side  of  the 
spine,  over  the  origin  of  one  of  the  last  two  or  three  ribs),  is  a 
very  constant  sign  of  ulcer — probably  the  most  constant  of  all 
its  signs  and  symptoms.  The  painful  spot  in  front  is  in  most 
cases  very  marked  or  acute,  and  is  situated  usually  either  just 
below  the  ensiform  process  nearly  in  the  median  line,  or  a  little 
to  the  left  of  it.  Exceptionally,  it  is  lower  down  or  still  more 
to  the  left,  and  may  even  be  found  to  the  right  of  the  median 
line.  In  such  tender  spots  pain  is  evoked  by  a  much  lighter 
pressure  than  over  the  tender  regions  so  often  found  in 
neurasthenics,  which  are  just  above  or  to  the  right  or  left  of 
the  umbilicus.  The  tender  spots  to  the  left  of  the  spine  are 
not  so  constantly  present,  but  are  found  in  about  one-third  of 
all  cases  of  gastric  ulcer.  You  should  not  forget,  however, 
that  in  neurasthenic  and  hysteric  patients  there  may  be  tender- 
ness on  pressure  alongside  the  spine  at  various  points,  even 
in  the  absence  of  gastric  ulcer. 

Vomiting  after  taking  food  is  another  rather  frecjuent  symp- 
tom of  gastric  ulcer.  The  vomiting  of  ulcer  often  occurs  one 
or  two  hours  after  eating,  when  digestion  is  approaching  its 
height,  and  is  easy,  as  a  rule,  not  accompanied  by  much  strain- 
ing. Moreover,  its  occurrence  is  followed  by  a  cessation  of 
the  pain.  In  these  two  respects  it  differs  from  the  vomiting 
of  cancer,  which  is  likely  to  be  difficult,  and  is  followed  b) 
little  or  no  relief  of  the  pain.  The  ejecta  are  most  frequently 
partly  digested  food  containing  either  a  normal  percentage  or 


ROUND    ULCER    OF    THE    STOMACH  539 

an  excess  of  free  HCl.  These  should  be  filtered,  and  careful 
quantitative  test  of  the  filtrate  for  excess  of  HCl  should  be 
made. 

If  you  are  not  prepared  to  make  quantitative  tests,  it  will 
be  of  importance  to  learn  at  least  whether  free  HCl  is  present 
or  not.  To  determine  this,  drop  into  the  stomach  contents — 
after  filtering,  if  possible,  2  or  3  drops  of  a  one-half  of  i  per 
cent,  solution  of  dimethyl-amido-azo-benzol  in  alcohol.  A 
brilliant  red  color  will  result  if  free  HCl  is  present;  otherwise 
the  licjuid  will  assume  a  yellow  color.  A  very  large  excess  of 
lactic,  or  possibly  other  organic  acids  may  also  produce  a  red- 
dish color,  and  in  doubtful  cases,  you  should  verify  such  find- 
ings by  the  Giinzburg  test  described  in  Lecture  IX. 

Hypersecretion  of  gastric  juice — i.e.  an  excessive  amount  of 
juice  with  a  high  or  normal  percentage  of  HCl — is  also  a  fre- 
quent accompaniment  of  ulcer.  This  hypersecretion  may  oc- 
cur only  during  digestion  or  also  during  fasting — continuous 
hypersecretion.  • 

It  is  exceptional  in  ulcer  to  find  deficient  HCl,  though  this 
occasionally  happens.  The  almost  constant  excess  of  HCl  is 
one  of  the  important  corroborative  signs  of  gastric  ulcer.  A 
stubborn  chronic  hyperchlorhydria  or  hypersecretion  may  be 
the  sign  of  a  latent  ulcer.  It  is  therefore  important  in  such 
intractable  cases  to  put  the  patient  to  bed  and  give  the  ulcer 
cure.  The  use  of  the  tube  in  suspected  ulcer  is  to  be  avoided 
as  endangering  perforation,  though  it  is  customai'y  for  experts 
to  employ  it  cautiously  in  chronic  cases  of  ulcer. 

The  complexion  of  the  patient  may  be  ruddy  and  fresh, 
though  more  frequently  it  is  pale,  especially  after  hemor- 
rhages. Loss  of  flesh  occurs  sooner  or  later,  but  this  is  less 
progressive  and  extreme  than  in  carcinoma. 

The  appetite  is  generally  good — often  excessive.  This  as- 
sists especially  in  differentiating  ulcer  from  cancer  and  chronic 
asthenic  gastritis,  though  not  from  simple  hyperchlorhydria 
or  sthenic  gastritis,  in  both  of  which  a  sharp  appetite  is  the 
rule.     Ulcer  patients  will  often  say  the  appetite  is  poor  when 


540  THE  GASTRO-INTESTINAL  CLINIC 

they  mean  that  they  restrict  food  on  account  of  its  conse- 
quences.    Constipation  often  coexists  with  gastric  ulcer. 

A  tumor  can  be  sometimes  felt,  especially  in  old  ulcers  in- 
volving dense  cicatrices  or  adhesions  \vith  neighboring  organs 
and  when  much  hypertrophy  of  the  pylorus  has  resulted.  Such 
a  tumor  is  usually  small,  of  cylindric  shape,  smooth  and 
less  movable  than  the  irregular,  nodular  cancers  of  the  pylorus. 

Complications — The  most  important  are  ( i )  rapid  and 
possibly  fatal  collapse  from  the  eroding  of  a  large  vessel  with 
resulting  serious  loss  of  blood,  which  is  not  always  vomited, 
and  is  to  be  recognized  by  the  usual  symptoms  of  shock  (faint- 
ness,  pallor,  cold  extremities,  etc.)  ;  (2)  partial  perforation 
with  consecjuent  patches  of  local  plastic  peritonitis  and  the 


) 


Fig.  73.  Perforated  chronic  ulcer.  (From  a  preparation  in  the  Museum 
of  the  Royal  College  of  Surgeons.  By  permission  of  the  Council.) 
Twice  the  natural  size.  The  ulcer  is  shaped  like  an  oyster-shell.  It  is 
funnel-shaped,  and  the  ridges  formed  by  the  submucous  and  muscular 
coats  are  well  seen.  The  peritoneum  is  perforated  by  an  oval  opening 
with  clean-cut  edges.  (From  Sidney  Martin's  "  Diseases  of  the 
Stomach.") 

formation  of  adhesions,  a  condition  very  difficult  to  diagnosti- 
cate, since  the  only  symptoms  are  a  more  persistent  pain,  and 
increased  sensitiveness  to  movements  of  the  adjacent  structures, 
with  sometimes  very  slight  fever;  (3)  perforation  with  es- 
cape of  gastric  contents  into  the  peritoneal  cavity,  with  the 
usual   immediate   symptoms   of   perforation — sudden    intense 


ROUND    ULCER    OF    THE    STOMACH  54I 

pain,  fall  of  temperature,  rapid  pulse,  leucocytosis,  etc. — and 
a  rapidly  supervening  general  peritonitis  which  is  almost  in- 
variably fatal  without  prompt  surgical  intervention;  (4)  sub- 
phrenic abscess,  which  is  a  rare  complication  of  ulcer,  but  a 
serious  one.  As  a  result  usually  of  a  small  perforation  and 
the  slow  escape  of  the  stomach  contents  into  some  portion 
of  the  space  between  the  stomach  below,  diaphragm  above,  and, 
laterally,  the  liver,  spleen  or  one  or  more  of  the  other  ab- 
dominal organs,  a  localized  abscess  forms  which  is  walled  off 
and  is  liable  to  rupture  into  any  of  the  adjacent  viscera,  into 
the  lung,  finding  its  outlet,  in  the  latter  event,  through  one 
of  the  bronchial  tubes,  or  into  the  peritoneal  cavity,  producing 
general  peritonitis.  The  abscess  often  contains  gas  as  well  as 
fetid  pus  and  food  particles.  The  recognition  of  this  condi- 
tion must  be  made  mainly  from  the  physical  signs  after  a 
thorough  examination  of  both  the  thorax  and  abdomen,  and 
the  subject  you  will  find  fully  discussed  in  the  works  on  phys- 
ical diagnosis.  An  examination  of  the  blood  in  the  event  of 
such  complication  should  reveal  leucocytosis,  which  would  be  a 
corroborative  sign. 

Sequels  of  Gastric  Ulcer. — A  contraction,  or  even  complete 
closure  of  either  the  cardiac  or  pyloric  orifice  of  the  stomach 
can  result  from  the  cicatrix  of  an  ulcer.  This  very  rarely 
happens  to  the  cardia,  since  it  is  seldom  the  seat  of  ulcer,  but 
is  a  very  frequent  occurrence  in  the  pylorus  or  its  vicinity. 
Such  a  stenosis  of  the  gastric  outlet  becomes  the  cause  of 
marked  dilatation  of  the  stomach  with  either  rapid  exhaustion 
and  death,  or  a  gradual,  but  very  serious,  and  often  fatal,  im- 
pairment of  the  health.  The  crampy  pains  which  had  ceased 
with  the  healing  of  the  ulcer  may  then  recur,  and  vomiting  of 
large  accumulations  of  fermenting  food  occurs  at  intervals  of 
a  day  or  two,  with  scanty  urine,  and  the  physical  signs  of  a 
dilated  stomach,  as  well  as  sometimes  the  finding  of  a  small, 
smooth,  elongated,  not  freely  movable  tumor  in  the  pyloric 
region. 

When   extensive   ulceration   has   existed   around   rny   part 


542  THE  GASTRO-INTESTINAL  CLINIC 

of  the  visctis,  near  its  middle  especially,  there  may  result  from 
the  scars'»such  a  marked  constriction  as  to  produce  the  hour- 
glass stomach.  Great  prostration,  profound  anaemia,  even  ca- 
chexia may  be  caused  by  frequent  bleedings  and  vomitings,  or 
from  ingestion  of  too  little  food  through  dread  of  pain. 

In  5  to  6  per  cent,  of  cases,  according  to  Boas,  gastric  ulcer 
is  followed  by  cancer,  which  develops  in  its  site,  beginning 
usually  at  the  edges  of  the  scar.  The  Mayos  and  other 
surgeons  give  a  much  higher  percentage.  (For  diagnosis  see 
Lecture  LXI.) 

Hour-GIass  Stomach.  — C.  L.  Scudder {Boston  Med.  and Sur.  Jour.,  Dec. 
22,  1904)  states  that  the  symptoms  of  hour-glass  stomach  are  those  of 
chronic  gastric  ulcer  plus  food-stasis.  Several  important  physical  signs 
are  given,  and  the  diagnosis  while  difficult  is  not  always  impossible. 
Moynihaji' s  szgji :  If  the  stomach  be  percussed  and  then  distended  with 
air  and  after  20  or- 30  seconds  percussed  again,  the  resonant  area  will 
have  increased  at  the  cardiac  end  of  the  stomach,  but  will  remain  the 
same  over  the  pyloric  end,  demonstrating  a  constricting  part. 

Wolfler's  1st  Sign. — If  a  tube  is  passed  and  the  stomach  washed  with  a 
known  quantity  of  water,  upon  measuring  the  return  water  there  will  be 
found  a  loss  corresponding  to  the  water  which  has  passed  through  the 
constricting  part  into  the  pyloric  pouch.  (This  sign  is  very  questionable — 
the  water  may  pass  through  the  pylorus.)  Woijler's  2d  sigfi  :  If  the 
stomach  is  washed  until  the  water  returns  clear,  a  sudden  gush  of  foul 
cloudy  fluid  may  occur  from  the  pyloric  pouch,  demonstrating  a  separa- 
tion between  the  two  parts. 

JaTvorski's  "  paradoxical  dilatation." — A  succussion  splash  is  obtained, 
the  tube  is  passed  and  the  stomach  is  emptied  apparently,  and  still  a  suc- 
cussion splash  can  be  obtained. 

Eiselsberg  pointed  out  the  importance  of  the  following  two  signs:  (a) 
Upon  distending  the  stomach  with  gas  or  air  a  bulging  on  the  cardiac  side 
is  visible  and  evident  to  percussion.  This  bulging  gradually  subsides  as 
the  air  passes  to  the  pyloric  loculus.  (b)  As  the  gas  passes  from  one  side 
of  the  constricting  part  to  the  other  the  stethoscope  will  detect  a  bubbling 
sound. 

Stockton  {Jour.  A.  M.  A.,  Dec.  11,  1909)  gives  the  following  sign: 
The  tube  passed  a  few  inches  beyond  the  cardia  obtains  stomach  contents; 
then,  being  pressed  farther,  after  a  little  resistance  it  apparently  gets 
into  a  second  cavity  from  which  contents  of  a  difi^erent  character  are 
obtained.  This  indicates  either  an  hour-glass  stomach  or  a  spasmodic 
contraction  between  the  second  and  last  thirds  of  the  stomach. 

The  Roentgen  rays  used  after  administration  of  a  bismuth  suspension 
should  be  a  decided  aid  in  the  diagnosis. 


LECTURE  LIII 

THE    DIAGNOSIS    OF    ULCER   OF   THE 
STOMACH 

The  diagnosis  of  peptic  ulcer  may  in  certain  cases  be  mani- 
fest at  once  from  the  group  of  symptoms  present  without  any 
further  examination  than  is  required  to  find  that  the  character-- 
istic  tender  points  are  present ;  or,  on  the  other  hand,  as  Riegel 
forcibly  puts  it,  one  may  meet  with  cases  of  it  in  which,  "  with 
the  help  of  all  our  methods  of  investigation,  it  will  be  impos- 
sible to  make  even  a  probable  diagnosis  of  the  disease."  This 
is  especially  true  in  the  earlier  stages,  before  large  hemor- 
rhages occur.  Indeed,  Ewald,  Leube,  Riegel,  and  other  emi- 
nent authorities  agree  in  admitting  that  an  absolute  diagnosis 
in  suspected  cases  is  often  impossible,  and  all  these  strongly 
advise  that  in  such  cases  the  therapeutic  test  be  made — that  is, 
that  the  patients  be  placed  upon  the  treatment  appropriate  to 
ulcer,  when,  if  a  cure  or  marked  improvement  result,  it  may  be 
inferred  that  ulcer  had  been  present.  The  probability  that 
ulcer  is  present,  and  that,  too,  in  an  advanced  form,  is  very 
great,  however,  whenever  there  are  hemorrhages  from  the 
stomach  which  recur  irregularly  from  time  to  time,  without 
a  very  marked  or  steadily  progressive  loss  of  flesh  and  strength 
or  the  gradual  development  of  cachexia,  especially  if- there  are 
no  signs  of  hepatic  cirrhosis  or  indications  of  so-called  vi- 
carious menstruation.  If,  besides,  there  are  the  characteristic 
pain  and  marked  tenderness  on  pressure  over  the  epigastrium 
near  the  ensiform  process  with  or  without  a  like  tenderness  to 
the  left  of  the  spine  over  the  origin  of  any  of  the  three  lowest 
ribs,  the  diagnosis  becomes  reasonably  certain.  Vomiting 
daily  after  one  or  more  of  the  meals,  especially  when  the  ejecta 

543 


544  THE  GASTRO-INTESTINAL  CLINIC 

contain  a  large  proportion  of  free  HCl,  would,  with  the 
other  symptoms  mentioned,  leave  scarcely  any  room  for 
doubt. 

Hemorrhage  from  the  stomach  being  the  most  diagnostic  of 
all  the  single  symptoms  of  ulcer,  it  is  very  important  to  ex- 
clude all  other  possible  sources  of  hemorrhage.  These  are 
chiefly:  the  lungs,  throat  and  nose;  the  gums;  hepatic  cirrhosis 
with  resulting  gastric  congestion;  heart  disease  causing  stasis; 
aneurismal  and  atheromatous  changes  in  the  arteries  of  the 
stomach  (probably  rare)  ;  vicarious  menstruation;  scurvy,  pur- 
pura, and  other  hemorrhagic  diseases;  and  hysteria.  A  very 
careful  history  and  physical  examination  will  usually  leave 
little  doubt.  It  is  to  be  remembered  that  blood  from  the 
lungs  is  usually  coughed  up,  and  is  apt  to  be  bright  red  and 
somewhat  frothy;  that  from  the  stomach  is  usually  dark. 
However,  blood  from  the  lungs  or  upper  air  passages  may  be 
swallowed,  and  vomited  after  remaining  some  time  in  the 
stomach. 

It  is  desirable  to  make  the  diagnosis  early,  before  hemor- 
rhage and  other  certain  signs  are  present.  Various  tests  have 
been  devised  as  aids  to  this  end.  Among  these  is  morning 
lavage  of  the  fasting  stomach.  If  microscopic  food  remnants 
are  found  in  the  wash  water  it  suggests  ulcer;  these  micro- 
scopic food  remnants  may  simply  be  retained  by  the  ulcer 
surface  or  they  may  be  due  to  slight  stagnation  caused  by 
spasm  of  the  pylorus,  the  result  of  an  ulcer  in  or  near  the  lat- 
ter. Grandauer  {Dent.  Med.  JVoch.,  Aug.  5,  1909)  has  de- 
veloped his  "  remains  test  "  on  this  principle.  He  gives  2  gm. 
of  bismuth  the  previous  evening;  in  the  morning  a  fat-zwie- 
back test  breakfast  is  given,  and  one  hour  later  the  stomach 
is  washed  with  100  c.c.  of  water  and  then  washed  again  until 
clear.  When  large  amounts  of  bismuth  are  recovered  it  points 
to  ulcer  or  catarrh.  The  latter  is  easily  excluded  and  the 
diagnosis  of  ulcer  is  reached. 

If  more  than  a  few  c.c.  of  active  gastric  juice  is  found  in 
the  morning  in  the  fasting  stomach,  without  food  remnants, 


DIAGNOSIS    OF   ULCER   OF   THE   STOMACH  545 

this  means  a  continuous  hypersecretion,  a  frequent  accompani- 
ment of  ulcer. 

Bonniger  {Berl.  Klin.  Woch.,  1908,  No.  8)  advises  pour- 
ing a  dilute  solution  of  HCl  into  the  stomach  of  the  patient 
with  suspected  gastric  ulcer.  If  ulcer  is  present  pain  arises 
promptly,  which  never  occurs  in  the  healthy  stomach.  The 
orthoform  test  is  the  converse  of  this :  8  grains  of  orthoform 
are  administered  during  the  pain  of  suspected  ulcer;  if  the 
pain  subsides  within  a  few  minutes  it  points  to  ulcer,  as 
orthoform  is  almost  inert  except  upon  raw  or  abraded  surfaces. 

The  finding  of  occult  blood  in  the  vomitus,  lavage  water  or 
stools,  has  much  the  same  significance  as  open  hemorrhage. 
Care  must  be  taken  that  the  patient  be  on  a  blood- free  diet  for 
a  sufiicient  time  before  the  test,  and  to  exclude  other  sources  of 
blood. 

Einhorn  {Med.  Rec,  April  3,  1909)  has  devised  an  ingeni- 
ous test  which  has  led  him  to  the  diagnosis  of  ulcer  in  a  num- 
ber of  cases  which  had  been  doubtful,  especially  of  duodenal 
ulcer :  The  patient  swallows  in  the  evening  the  duodenal 
bucket  in  a  gelatin  capsule.  To  the  bucket  is  attached  a 
braided  silk  thread,  English  No.  5,  long  enough  to  allow  the 
bucket  to  pass  75  cm.  from  the  teeth  and  the  thread  to  be  at- 
tached to  the  patient's  shirt  or  ear.  The  bucket  is  withdrawn 
from  the  fasting  stomach  in  the  morning  and  the  thread  care- 
fully inspected  for  brown  or  black  discoloration.  According  to 
the  distance  of  the  stain  from  the  lips  the  ulcer  is  diagnosed  as 
in  the  oesophagus,  cardia,  lesser  curvature,  pylorus  or  duode- 
num.    The  test  is  not  available  for  other  parts  of  the  stomach. 

Adler  and  Ashbury  ^  have  found  the  x-rays  of  considerable 
value  in  the  diagnosis  of  ulcers  of  the  stomach  and  duodenum. 
The  examination  is  made  four  to  six  hours  after  the  admin- 
istration of  a  single  dose  of  bismuth.  Other  investigators 
also  report  favorable  results. 

But  dependence  must  not  be  placed  on  any  one  test.  The 
whole  picture  obtained  by  careful  history  and  painstaking  ex- 
^ Journal  A.  M.  A.,  May  21,  1910.     P.  1721. 


546  THE  GASTRO-IXTESTIXAL  CLIXIC 

amination  must  be  considered  in  any  doubt'ful  case.  It  is  to 
be  remembered  that  ulcer  patients  characteristically  have  their 
symptoms  in  attacks  of  variable  duration,  with  intervals  of 
complete  or  partial  relief;  that  during  the  attacks  the  symp- 
toms recur  regularly  every  day  and  with  definite  relation  to  the 
taking  of  food;  that  the  attacks  are  likely  to  recur  indefinitely 
and  with  increasing  severity  until  cured  by  medical  or  surgical 
treatment. 

The  Diagnosis  from  Ulcer  of  the  Duodenum. — Round  ulcer 
of  the  duodenum  needs  to  be  differentiated.  It  usually  affords 
symptoms  similar  to  those  of  gastric  ulcer  (though  more  fre- 
quently even  than  the  latter  it  runs  its  course  without  any 
symptoms),  except  that  hematemesis  is  much  less  common,  the 
blood  in  case  of  hemorrhage  being  more  likely  to  pass  ofT  by 
the  bowels  exclu5i\"ely.  and  the  pain,  as  well  as  the  area  which 
is  painful  on  pressure,  is  more  on  the  right  side,  usually  in  the 
prolonged  right  parasternal  line  about  one  or  two  finger 
breadths  below  the  gall-bladder.  Pain  usually  begins  2  to  5 
hours  after  eating,  and  is  relieved  by  taking  more  food.  Vom- 
iting may  occur,  as  a  reflex  probably  of  the  pain,  but  usually 
does  not  relieve  the  pain,  as  it  does  in  gastric  ulcer.  Hyper- 
chlorhydria  is  by  no  means  so  frequent  an  accompaniment  as  in 
ulcer  of  the  stomach.  Duodenal  is  less  prevalent  than  gastric 
ulcer,  and.  unlike  the  latter,  is  \'ery  much  more  frequent  in 
men  than  in  women — 79  per  cent,  are  in  men  according  to 
Collin — and  about  one-seventh  of  all  the  cases  are  in  children 
under  ten  years.  ]\Iayo  finds  duodenal,  more  frequent  than 
gastric,  ulcer,  but,  as  Einhorn  well  says,  this  is  probably  due  to 
the  fact  that  duodenal  ulcer  is  much  more  likely  to  result  in 
surgical  complications. 

You  will  need  to  think  also  of  the  pain  from  gall-stones — 
hepatic  'colic — but  here  the  pain  and  tenderness  are  consider- 
ably to  the  right  of  the  median  line,  the  pain  is  usually  far 
more  intense,  and  there  is  no  connection  bet^^"een  the  attacks 
and  the  period  of  digestion.  Hemorrhage  will  be  absent,  and 
jaundice  with  some  fever  often  present. 


DIAGNOSIS    OF    ULCER   OF   THE    STOMACH 


547 


Differential  Diagnosis — In  summarizing  the  points  in  the 
differential  diagnosis  between  gastric  ulcer  and  the  diseases 
which  resemble  it,  I  cannot  do  better  than  to  follow  the  lead 
of  Ewald  and  other  authors,  who  have  grouped  the  symptoms 
in  a  tabular  form.  This  I  have  done,  and  present  for  you  the 
results  in  the  following  table,  in  which  the  observations  of 
numerous  high  authorities,  as  well  as  my  own,  have  been  care- 
fully compared  and  sifted,  all  statements  having  been  omitted 
as  to  which  there  is  not  a  concurrence  of  several  observe ers : 


Pain 


Hemor- 
rhage 


Vomit- 
ing 


Ulcer  of  the 
Stomach 


There  may  be  all 
forms  and  degrees. 
Comes  on  at  variable 
periods  after  eating, 
often  within  half  an 
hour,  and  lasts  till  the 
stomach  emptiesitself 
either  in  the  normal 
way  or  by  vomiting. 
May  be  boring  or 
burning,  but  is  often 
spasmodic.  Worse 
after  solids.'  Felt  in 
certain  spots  and  in- 
creased by  pressure 
there. 

Either  small  or  large 
amounts  of  blood  may 
be  vomited,  of  either 
red  or  dark  color,  and 
this  is  apt  to  recur  one 
or  more  times  before 
controlled.  Then  no 
further  hemorrhage 
usually  for  weeks  or 
months.  Following 
the  hematemesis 
brownish-black 
altered  blood  ;  occult 
blood  in  stools. 

A  frequent  symp- 
tom, and  liable  to  oc- 
cur daily.  Comes  on 
either  .shortly  after 
eating  or  later.  It  is 
usually  easy,  not  ac- 
companied by  strain- 
ing. Amount  propor- 
tioned to  size  of  last 
meal.  Ejecta  rarely 
rancid,  but  show  free 
HCl.  Vomiting  usii- 
ally  relieves  the  pain. 


Excess  of  HCl, 

with  or  without 

Gastritis 


Comes  on  one  to 
three  hours  after 
eating,  and  apt  to 
continue  during 
remaining  period 
of  digestion.  Usu- 
ally of  burning 
character.  Re- 
lieved by  more 
food,  especially 
nitrogenous,  or 
large  doses  of  al- 
kalies. Pressure 
neither  increases 
nor  relieves  it. 


No  blood  vom- 
ited or  passed  by 
bowels. 


Cancer  of  the 
St07nach 


Less  frequent, 
but  happens  in 
the  worst  cases, 
when  it  occurs  at 
about  the  acme  of 
digestion— one  to 
three  hours  after 
eating.  Vomiting 
usually  relieves 
the  pain. 


Usually  not  violent, 
but  continuous.  Not 
relieved  by  vomiting, 
by  more  food  or  by 
alkalies.  Not  in 
creased  by  moderate 
pressure,  though  deep 
palpation  may  aggra 
vate. 


.Small  (rarely  large) 
amounts  of  blood  are 
vomited  at  times, 
usually  dark  like  cof- 
fee grounds.  The 
relatively  small  hem 
orrhages  may  recur 
frequently,  the  blood 
showing  both  in  the 
vomit  and  stools,  as 
altered  or  occult 
blood. 


Likely  to  occur 
once  in  two  or  three 
days  only,  when  large 
amounts  of  sour  and 
offensive  matter 
ejected,  showing  ab 
sence  of  free  HCl  and 
often  presence  of  lac- 
tic acid.  The  vomit- 
ing often  accompa- 
nied by  straining. 
Vomiting  does  not 
relieve  the  pain  as  a 
rule. 


Gastralgta 


Not  connect- 
ed with  the 
taking  of  food 
or  limited  to 
the  period  of 
digest  ion. 
Comes  on  in 
spells  at  irreg- 
ular intervals, 
often  many 
days  apart. 
Often  relieved 
by  pressure. 
A  s  sociated 
sometimes 
with  neuralgia 
elsewhere. 
No  blood  is 
omited  o  r 
passed  with 
stools. 


Vo  m  i  t  ing 
exceptional, 
and  w^hen  it 
does  occur,  in 
no  way  char- 
acteristic. 


548 


THE    GASTRO-INTESTINAL    CLINIC 


Gastric 
Secre- 
tiofl  and 
Diges- 
tion 


Tumor 


Ulcer  of  the 
Stomach 


Free  HCl  usually  in 
excess  and  very 
active  digestion  of 
meat,  eggs,  and  milk; 
starch  digestion  de- 
layed. 


Perfora- 
tion 


Com- 
plexion 


Flatu- 
lence 
and 
Belch- 
ing 


Appe- 
tite 


Tongue 


Excess  of  HCt, 

with  Q}- without 

Gastritis 


Free  HCl  al- 
ways in  excess 
during  digestion, 
which  is  active  for 
proteids  and  slow 
for  starch. 


Age 


Sex 


None  except  in  old 
complicated  cases, 
when  a  small,  smooth, 
cylindric  or  egg- 
shaped  resistance 
maj'  sometimes  be 
made  out  in  the  re- 
gion of  the  pylorus. 
It  is  usually  fixed  and 
immovable. 

Always  possible, 
and  may  occur  in  per- 
sons who  have  not 
previously  com- 
plained. 

Fresh  and  ruddy 
often,  except  when 
ulcer  has  long  con- 
tinued; anaemia  and 
pallor  follow  each 
hemorrhage,  but  are 
soon  recovered  from, 
except  when  ulcer  is 
associate  d  with 
chlorosis. 

No  offensive  belch 
ing,  but  likely  to  be 
much  flatulence  in 
the  bowels.  Apt  to 
be  much  fermenta- 
tion of  the  carbo- 
hydrates. 

Generally  good 
but  patient  often  pre- 
vented from  eating 
by  fear  of  the  pain. 


Red  and  often  dry  ; 
may  be  coated  at  the 
back.  Pale  after 
hemorrhage. 

Most  frequent  be- 
tween twenty  and 
forty,  but  very  com- 
mon in  middle  age 
and  occurs  in  old  age. 

About  twice  as  fre- 
quent in  women  as  in 
men. 


None  at  all. 


Never  occurs. 


Variable  ;  often 
sallow  from  intes- 
tinal and  hepatic 
complications,  but 
sometimes  health 
f  ul  in  recent 
cases. 


The  same  as  in 
ulcer. 


Usually  sharply 
increased,  but  ex 
ceptionally  poor 
in  advanced  cases 
with  gastritis. 


Clean  and  red 
as  a  rule,  but 
often  coated  at 
the  back. 

Most  frequent 
in  middle  life,  but 
may  occur  at  any 
age. 


Probably  no 
marked  differ- 
ence. 


Caticer  of  the 
Stomach 


Free  HCl  generally 
absent  or  deficient, 
and  digestion  of  pro- 
teids poor,  except  in 
that  form  of  cancer 
which  develops  in 
the  site  of  an  ulcer. 
Lactic  acid  usually 
present.  Boas-Oppler 
bacilli  usually  discov 
erable  in  stomach 
contents. 

A  palpable  tumor 
develops  at  some 
stage  in  nearly  all 
cases.  It  is  usually 
uneven,  sensitive  on 
palpation,  and  mov 
able,  not  fixed. 


Never  in  the  earlier 
stages,  but  in  the  last 
stage  occurs  in  six  per 
cent,  of  all  cases. 

Bad  after  the  first 
stage,  and  becomes 
progressively  worse 
until  cache.xia  estab 
lished. 


Usually  marked 
flatulence:  much  of- 
fensive gas  passing 
both  ways. 


No  constant 
departure 
from  normal 
cond  i  t  i  on  s. 
Digestion 
usually  good. 


No  tumor. 


Gastralgia 


Bad  nearly  always, 


Pale    and    badly 
furred. 


Rare  before  thirty  ; 
most  frequent  in  ad- 
vanced years. 


Statistics  disagree. 
Probably  no  impor 
tant  difference. 


Never  occurs. 


Most  fre- 
quently pale, 
from  impaired 
general 
health. 


Little  or  no 
gas  may  pass 
either  way, 
butsometimes 
excessive  ner- 
vous belching 
of  odorless 
gas. 

Good  as  a 
rule,  but  may 
be  capricious. 


May  be  nor- 
mal or  in  any 
condition,  ac- 
cording: to 
complications. 

Most  f  r  e- 
quent between 
the  ages  of 
eighteen  and 
thirty-five. 

Much  more 
frequent  in 
women. 


LECTURE  LIV 

THE    TREATMENT   OF   GASTRIC    ULCER- 
EROSIONS    OF   THE    STOMACH 

The  mortality  from  gastric  ulcer  has  greatly  lessened  as  a 
result  of  recent  improvements  in  the  treatment.  Brinton  esti- 
mated it  at  50  per  cent.,  whereas  it  is  now  stated  by  several 
authors  as  not  exceeding  10  per  cent.  In  any  case,  the  prog- 
nosis will  depend  upon  many  things — the  absence  of  serious 
complications,  the  youth  and  vigor  of  the  patient,  and,  above 
all  else,  his  ability  and  willingness  to  submit  to  a  course  of 
methodical  treatment  in  bed.  When  the  special  ulcer  rest 
cure  is  instituted  and  strictly  carried  out  during  an  early  stage 
of  the  disease,  recovery  nearly  always  follows  within  a  few 
weeks,  and  is  often  permanent.  When  the  affection  has  long 
existed,  and  the  ulcer  is  deep,  as  shown  by  large  hemorrhages, 
the  outlook  is  less  favorable.  When  complicated  by  gastritis 
or  adhesions,  the  disease  is  likely  to  be  very  obstinate,  and  when 
stenosis  of  either  orifice  has  resulted,  a  cure  is  impossible  with- 
out surgery.  A  considerable  proportion  of  cases  heal  sponta- 
neously in  the  course  of  time — often  many  years — under  favor- 
able circumstances,  in  consequence  probably  of  a  diminution 
in  the  secretion  of  the  gastric  g-lands,  the  excess  of  HCl  hav- 
ing, as  a  result  of  exhaustion  or  atrophy,  given  place  to  a  de- 
ficiency of  the  same.  But  there  are  few,  if  any,  diseases  in 
which  skilled  treatment  at  the  proper  time  can  accomplish  such 
brilliant  results. 

Treatment,  Prophylactic — In  every  case  of  marked  HCl 
excess,  especially  if  there  is  pain  at  the  height  of  digestion,  you 
should  consider  that  ulcer  is  threatened,  if  not  already  present, 

549 


550  THE    GASTRO-INTESTINAL    CLINIC 

and  insist  upon  a  rational  and  persistent  treatment  until  normal 
conditions  have  been  restored,  and  even  then  urge  strenuously 
that  the  patient  so  alter  his  diet  and  unhygienic  mode  of  life, 
t^at  there  shall  not  be  a  speedy  return  of  the  secretory  derange- 
ment. For  instance,  it  is  quite  useless  to  cure  a  patient  of  hyper- 
chlorhydria,  if,  so  soon  as  you  pronounce  the  percentage  of  HCl 
in  the  stomach  contents  to  be  normal,  he  be  permitted  to  eat  ir- 
regularly, hastily,  and  excessively  a  diet  consisting  mainly  of 
meat  and  other  stimulating  animal  foods,  with  acids,  alco- 
holic liquors,  the  sharpest  condiments,  and  other  things  that 
are  highly  exciting  and  irritating  to  the  gastric  glands,  es- 
pecially if  at  the  same  time  he  exercise  little  and  overtax  his 
brain  and  nervous  system  in  many  ways.  It  ought  to  be  pos- 
sible to  make  such  a  patient  understand  that  the  same  causes 
which  produced  his  disease  before  will  still  more  easily  pro- 
duce it  again,  if  he  continue  to  keep  them  in  action. 

Cure  the  hyperchlorhydria,  then,  by  the  methods  which  I 
have  hitherto  described,  including  full  doses  of  alkalies  and 
belladonna  or  'atropine,  a  bland  diet,  and  by  insisting  upon  the 
proper  use  of  the  teeth.  Thorough  chewing  of  the  food  spares 
the  stomach' mechanically;  the  abundant  saliva  thus  produced 
does  its  own  work,  and  also  neutralizes  much  acid;  and  slow 
eating  is  one  of  the  best  preventives  of  overeating. 

Moreover,  since  anaemia  and  chlorosis  predispose  strongly  to 
ulcer,  you  should  endeavor  always  by  exercise  out-of-doors, 
cool  or  cold  sponge  baths  and  other  measures,  both  hygienic 
and  medicinal,  to  improve  the  quality  of  the  blood.  When 
in  such  cases  the  stomach  is  not  too  sensitive,  you  may  often 
administer  safely  such  mild  ferric  preparations  as  Blaud's 
pills,  neutral  solution  of  the  albuminate  of  iron,  etc.,  and  when 
these  do  not  suit,  preparations  of  bone-marrow  often  meet  the 
requirements  well,  increasing  the  number  of  red-blood  cor- 
puscles without  disturbing  the  stomach.  The  tincture  of  iron, 
which  is  usually  remarkably  effective  in  other  cases,  will  ag- 
gravate any  case  in  which  there  is  excess  of  HCl,  and  the 
milder  preparations  of  iron  should,  therefore,  be  chosen  here. 


THE    TREATMENT    OF    GASTRIC    ULCER  55 1 

I  have  sometimes  found  i-  to  2-teaspoonful  doses  of  Roncegno 
water  to  suit  well. 

Treatment,  Curative — A  recent  French  writer,  Lemoine, 
lays  down  two  fundamental  indications  in  the  treatment  of 
gastric  ulcer :  ( i )  To  put  the  stomach  at  complete  rest,  and 
(2)  to  modify  the  gastric  secretion,  that  is,  reduce  the  hyper- 
chlorhydria.  To  do  these  things  effectively  is  often  sufficient, 
but  Lemoine  very  properly  adds  these  further  special  indica- 
tions : 

(i)  Quiet  the  pain.  (2)  Allay  vomiting.  (3)  Prevent 
dilatation  of  the  stomach.  (4)  Preclude  or  arrest  hema- 
temesis.     To  which  I  may  add:  (5)  Prevent  perforation. 

The  diet  with  confinement  to  bed  must  be  depended  upon 
mainly  for  the  fulfillment  of  all  the  above-mentioned  indica- 
tions. To  put  the  stomach  at  rest  physically  and  functionally, 
it  will  be  necessary,  first,  to  keep  the  patient  in  bed  for  a  time — 
three  weeks  at  least,  and  four  to  six  weeks  are  better — and  for 
one  week  to  feed  exclusively  per  rectum,  or  longer  in  the  worst 
cases.  Fox,  Forster,  and  Williams  first  advised  such  a  rest 
cure  for  ulcer  of  the  stomach,  but  to  Ziemssen  and  Leube  in 
Germany  belongs  the  credit  of  proving  the  efficacy  of  the 
method  and  establishing  it  in  the  favor  of  the  profession.  Be- 
sides complete  physical  rest  with  rectal  feeding  at  first,  the 
Ziemssen  and  Leube  method  comprises  also  the  use  of  hot 
poultices  or  hot  compresses  over  the  stomach.  These  should 
be  kept  constantly  in  place. 

The  nutrient  enemas  should  be  introduced  two  to  four  times 
a  day,  according  to  the  tolerance  of  the  bowel,  after  a  prelimi- 
nary cleansing  enema.  (See  Lecture  XXL  for  particulars  con- 
cerning rectal  feeding. ) 

Dorkin,  in  a  large  series  of  cases,  has  continued  rectal  feed- 
ing for  twenty-three  days  with  good  results,  and  in  one  case  in 
my  own  practice  the  patient  was  nourished  exclusively  by  the 
rectum  for  four  weeks  without  serious  loss  of  flesh  or  nu- 
trition, but  in  gastric  ulcer,  unless  hemorrhage  should  con- 
tinue (a  most  unlikely  event  under  such  a  method  of  treat- 


55-  THE  GASTRO-IXTESTIXAL  CLIXIC 

ment),  xery  cautious  feeding  by  the  mouth  can  be  resumed 
usually  l3y  the  end  of  a  week.  ]\Iilk  and  limewater.  equal 
parts,  will  constitute  the  best  food  to  begin  with,  and  when 
tjhere  is  any  remaining  irritability  of  the  stomach,  it  will  be 
well  to  give  half  a  tumblerful  every  hour  for  a  day  or  two, 
though  sometimes  it  is  necessary  to  begin  with  a  tablespoonful 
every  half  hour.  After  the  first  few  feedings,  and  with  the 
vomiting  over,  ecjual  parts  of  milk,  lime  water,  and  ricewater, 
or  barley  water  may  be  taken  in  the  same  way.  After  two 
days,  the  amount  of  this  combination  can  usually  be  increased 
to  one  or  one  and  a  half  tumblers  every  two  hours,  provided 
there  be  no  decided  atony  or  dilatation  of  the  stomach.  Alean- 
while,  it  will  be  advisable  to  continue  the  administration  daily 
of  two  enemas  at  least  for  another  week.  Beef  tea  and 
bouillon  are  little  more  than  solutions  of  the  meat  salts,  which 
are  exceedingly  stimulating  to  the  gastric  glands,  and  are  there- 
fore best  not  introduced  into  the  stomach  in  such  cases.  Raw, 
lightly  boiled  or  poached  eggs  without  pepper,  and  only  slightly 
salted,  are  much  safer,  and  one  of  these  may  be  allowed  once 
a  day  in  addition  to  the  milk  mixture  from  the  fourth  to  the 
seventh  day ;  twice  a  day  from  the  eighth  to  the  eleventh  day, 
and  thereafter  three  times  a  day.  Calf's-foot  jelly  makes  an- 
other bland  and  nourishing  addition  at  this  stage. 

After  the  eighth  day,  the  patient  is  to  be  allowed  every  three 
hours  a  larger  feeding  as  follows  :  two  tumblers  of  the  milk 
mixture,  in  which  a  cracker  may  be  dissolved,  and  besides,  once 
a  day,  instead  of  the  milk,  a  tumbler  of  a  smooth,  well-strained 
puree  made  of  corn,  peas,  celery,  or  asparagus;  this,  in  ad- 
dition to  the  eggs  or  calf's-foot  jelly,  provided  always  the 
stomach  proves  to  be  tolerant  of  the  additions. 

By  the  end  of  two  weeks  it  is  usually  safe  to  add  some  of  the 
blander  starchy  preparations,  such  as  flaked  rice.  Cream  of 
\Mieat,  Oat  Flour,  and  other  similar  finely  ground  and  bolted 
cereals,  which  are  to  be  thoroughly  well  cooked  and  served 
with  fresh  milk  or  even  good  fresh,  sterile  cream,  when  the 
latter  is  well  tolerated,  but  not  with  stigar.    Still  better  are  the 


THE    TREATMENT    OF    GASTRIC    ULCER  553 

well-dextrinized   cereal   foods  now  on  the  market,   includins- 

o 

Force,  Grape  Nuts,  etc.  Small  feedings  every  three  hours,  lim- 
ited strictly  to  such  viands  as  those  above  mentioned,  with  the 
early  addition  of  good  stale  bread  and  butter,  and  baked  white 
potato,  thoroughly  masticated,  should  be  insisted  upon  for 
fully  three  weeks,  and  then  a  more  liberal,  but  rational,  diet 
may  be  gradually  resumed.  The  patient  will  be  safer  without 
meat,  especially  meat  fiber  not  hashed,  for  months  after  his  ap- 
parent recovery,  and  should  avoid  still  more  stringentlv,  for  a 
longer  period  yet,  all  alcoholic  beverages,  spices,  or  condiments 
(except  sparingly  table  salt),  the  sharper  acids,  as  vinegar  and 
very  acid  fruits,  the  coarser  or  cruder  vegetables,  fried  foods, 
pickles,  and  all  the  coarser  grains.  The  ordinary  rough,  un- 
bolted oatmeal  and  bran  bread,  as  well  as  the  hard  crust  of  any 
bread,  dry  toast,  zwieback,  etc.,  are  hurtful  in  these  cases,  be- 
ing mechanically  irritating,  unless  previously  softened  or 
chewed  a  very  long  time  before  swallowed.  (See  Lecture 
XX.) 

Massage,  during  the  rest  in  bed,  should  be  given  once  or 
twice  daily  over  the  entire  body,  except  the  abdomen,  which 
must  be  strictly  avoided — because  of  the  stimulating  effect 
upon  the  gastric  glands.  Constipation  may  be  overcome  by 
saline  laxatives.  It  is  a  general  custom  to  give  a  glass  of  warm 
Carlsbad  water  or  a  teaspoonful  of  Carlsbad  salts  in  a  glass 
of  warm  water  every  morning.  This  aids  in  preventing  con- 
stipation, and  also  in  reducing  the  hyperchlorhydria. 

By  the  end  of  three  or  four  weeks,  in  most  cases,  you  should 
begin  very  gradually  to  accustom  the  patient  to  exercise  again, 
in  the  same  way  as  after  the  Weir-Mitchell  rest  treatment  of 
nervous  diseases. 

Treatment,  Medicinal,— The  milder  cases,  that  receive 
this  treatment  by  rest,  rectal  feeding,  and  very  restricted  diet, 
will  require  little  medicine  for  the  main  disease,  and  there  are 
not  likely  to  be  any  complications  demanding  special  treatment 
in  cases  thus  managed. 

If  there  should  be  pain  or  vomiting  in  spite  of  the  regimen 


554  THE  GASTRO-INTESTINAL  CLINIC 

just  described,  pellets  of  ice  swallowed  and  allowed  to  dissolve 
in  the  stomach  will  frequently  afford  relief.  These  are  useful 
also  to  quench  thirst  during  the  period  of  exclusively  rectal 
feeding,  and  at  the  same  time  the  mouth  may  be  rinsed  as 
often  as  desired  with  cold  w^ater.  If  there  should  be  very 
much  thirst  in  spite  of  these  measures,  small  sips  of  cool  water 
may  be  allowed  as  often  as  necessary.  When  there  is  per- 
sistent pain  or  burning,  with  no  food  or  only  liquids  being 
taken  by  the  mouth,  it  is  usually  dependent  upon  excessive 
HCl,  and  relief  will  then  usually  follow  the  administration  of 
half  to  one  teaspoonful  doses  of  sodium  bicarbonate  dissolved 
in  a  tumbler  of  warm  (not  hot)  water,  given  half  an  hour  be- 
fore the  three  chief  feedings  daily.  In  all  cases  that  prove 
stubborn,  and  in  the  severe  or  advanced  ones  from  the  start, 
it  is  well  to  institute  the  Kussmaul-Fleiner  treatment.  Fleiner 
washes  out  the  stomach  before  breakfast,  and  then  introduces 
through  the  tube  lo  to  15  grams  of  bismuth,  suspended  in 
about  6  ounces  of  water.  But  I  have  found  that  administering 
40  to  60  grains  in  a  draught  of  water,  three  times  a  day  an 
hour  before  food,  usually  answers  every  purpose.  Singularly 
enough,  so  far  from  always  constipating,  I  have  found  these 
large  doses  sometimes  to  aid  in  overcoming  constipation. 
When,  however,  there  is  a  contrary  result,  enemas  of  4  to  12 
ounces  of  olive  oil,  or  cotton-seed  oil,  every  two  or  three 
nights,  will  usually  secure  good  movements  without  irri- 
tation. 

The  design  is  to  have  the  bismuth  form  a  protective  coating 
over  the  mucous  membrane  of  the  stomach.  In  cases  com- 
plicated with  acid  gastric  catarrh,  in  which  a  profuse  secretion 
of  mucus  covers  the  membrane,  it  is  better,  provided  there  has 
been  no  hemorrhage  for  a  long  time,  to  first  wash  out  and 
then  introduce  the  remedy  through  the  tube,  the  patient  mean- 
while being  caused  to  lie  down  in  such  a  position  as  to  allow 
the  bismuth  to  fall  especially  upon  the  part  of  the  stomach 
where  the  ulcer  is  located.  There  would  be  a  manifest  ad- 
vantage in  thus  following  the  Fleiner  method  exactly,  when 


THE    TREATMENT    OF    GASTRIC    ULCER  555 

the  tube  can  be  used  skillfully  and  gently  without  endangering- 
a  hemorrhage. 

My  own  experience  with  the  bismuth  treatment  has  been 
very  satisfactory,  and  I  have  not  found  it  necessary  to  use  the 
tube  at  all  in  ulcer  cases ;  but  have  administered  the  drug  in 
30  to  40  grain  doses  in  water,  every  three  to  six  hours  before 
food —  /.  e.,  on  an  empty  stomach. 

The  Lenhartz  Cure. — I  have  never  used  the  Lenhartz  treat- 
ment, and  have  had  such  uniformly  satisfactory  results  from 
the  routine  laid  down  above  that  other  methods  seem  hardly 
necessary.  Various  observers,  however,  are  reporting  good 
results  from  the  Lenhartz  routine,  and  the  essential  points  of 
the  latter  are  presented  below.  Lenhartz  protests  against  a 
regimen  which  tends  to  further  deplete  the  blood  and  lessen  the 
vitality  of  a  patient  who  is  already  anaemic  and  under-nour- 
ished as  the  result  of  more  or  less  hemorrhage  and  starv^ation; 
accordingly,  he  begins  at  once,  even  if  hemorrhage  has  oc- 
curred the  same  day,  a  diet  rich  in  albumin,  rapidly  increasing 
the  same  until  a-  high  caloric  value  is  reached.  The  diet  is  as 
follows :  First  day  after  last  hemorrhage,  2  eggs,  200  c.c.  milk. 
One  additional  tgg  is  given  each  day  until  eight  are  taken; 
this  number  is  continued  daily.  100  c.c.  milk  are  added  each 
day  until  a  liter  is  reached;  this  is  continued  daily.  On  the 
third  day  20  gm.  of  sugar  are  given,  with  the  eggs;  this  is  in- 
creased by  10  gm.  every  second  day,  until  50  gm.  are  reached; 
this  amount  is  continued  daily.  On  the  sixth  day  35  gm.  of 
raw  chopped  meat  are  given ;  this  is  increased  to  70  gm.  on  the 
seventh  day,  and  the  same  amount  continued.  On  the  seventh 
day  100  gm.  of  milk-rice  are  given;  this  is  increased  to  200  gm. 
on  the  ninth  day,  and  to  300  gm.  on  the  eleventh  day ;  this 
amount  is  continued  daily.  On  the  eighth  day  20  gm.  of 
zwieback  are  given ;  ninth  and  tenth  days,  40  gm. ;  eleventh  and 
twelfth  days,  60  gm. ;  thirteenth  day,  80  gm. ;  fourteenth  day, 
100  gm.  On  the  tenth  day  and  daily  thereafter  50  gm.  of 
raw  ham  are  given.  Butter  is  also  given  on  the  tenth  day,  20 
gm. ;  on  the  eleventh  day  this  is  increased  to  40  gm.,  and  con- 


556  THE    GASTRO-INTESTINAL    CLINIC 

tinued  in  this  amount.  The  patient  receives  280  calories  the 
first  day,  3073  calories  the  fourteenth  day. 

The  milk  is  iced  and  fed  with  a  spoon;  the  eggs  are  beaten 
and  the  cup  and  spoon  stood  in  ice.  After  the  seventh  day 
four  of  the  eggs  may  be  cooked.  An  ice  bag  is  applied  to  the 
epigastrium  almost  continuously  for  two  weeks.  No  effort 
is  made  to  move  the  bowels  for  at  least  one  week.  Rest  in  bed 
for  at  least  four  weeks  is  essential.  Bismuth  in  2  gm.  doses  is 
given  two  or  three  times  a  day  for  ten  days.  Iron  is  given 
later. 

Minkowski,  Senator,  Lambert,  and  others  have  used  the  diet, 
somewhat  modified,  with  apparently  good  results. 

Cohnheim,  in  his  textbook,  recommends  the  use  of  olive  oil 
in  ulcer,  claiming  good  results  in  numerous  cases  which  had 
obstinately  resisted  other  forms  of  treatment.  He  gives  one- 
half  to  one  wineglassful  of  oil  in  the  morning  before  break- 
fast, and  a  half  ounce  or  less  before  the  noon  and  evening 
meals.  The  treatment  is  said  to  be  especially  effective  when 
pylorospasm  is  present.  When  the  oil  is  objectionable,  an  al- 
mond oil  emulsion  may  be  substituted. 

Treatment  of  Complications  and  Sequels. — Copious  hemor- 
rhage is  not  to  be  feared  while  the  patient  is  on  a  strict  rest 
cure  with  the  diet  already  laid  down.  If  it  should  occur  under 
other  conditions,  put  the  patient  immediately  to  bed,  feed  by 
the  rectum,  administering  small  pellets  of  ice  by  the  mouth, 
and  place  an  ice  bag  over  the  epigastrium.  The  tube  is  dis- 
tinctly dangerous  in  these  cases  in  most  hands,  yet  Ewald  re- 
cords having  checked  otherwise  uncontrollable  hematemesis  by 
washing  out  the  stomach  with  ice  water.  You  will  do  well  to 
give  large  doses  of  bismuth  suspended  in  limewater.  A  good 
soluble  form  of  ergot  should  also  be  promptly  administered, 
and  repeated  if  necessary.  Stimulate  per  rectum  and  hypo- 
dermically  only  when  collapse  threatens ;  keep  the  head  low 
and  maintain  the  body  heat.  The  patient  should  be  quieted 
and  peristalsis  checked  by  sufficient  doses  of  morphine,  hypo- 
dermically.     Calcium   chloride   may   be  given   by   rectum   or 


THE    TREATMENT    OF    GASTRIC    ULCER  557 

cautiously  by  mouth,  in  an  effort  to  increase  the  coagulabihty 
of  the  blood.  Gelatin  for  the  same  purpose  is  also  much  used, 
a  2  per  cent,  sterile  solution  being  given  by  hypodermoclysis, 
or  frequent  small  doses  of  a  lo  per  cent,  solution  by  mouth. 
Adrenalin  or  suprarenal  extract  may  be  given  by  mouth,  some- 
times with  good  results.  Some  authors  even  give  it  hypo- 
dermically,  but  this  is  probably  unwise;  the  raising  of  the  gen- 
eral blood  pressure  would  be  apt  to  more  than  offset  any  local 
contracting  effect  upon  the  bleeding  vessel. 

In  the  case  of  a  complete  perforation  into  the  peritoneal 
cavity,  a  skilled  abdominal  surgeon  should  be  summoned  im- 
mediately, and  meanwhile  absolute  rest  of  the  patient  secured 
with  abstinence  from  food  or  drink  (except  ice  pellets),  and 
an  ice  bag  should  be  placed  over  the  abdomen.  Opium  in  full 
doses  is  also  desirable  for  its  cjuieting  effect.  Complete  per- 
foration is  almost  invariably  fatal  unless  the  patient  is  operated 
upon  within  a  few  hours  after  this  accident;  hence  no  time 
should  be  lost.  In  doubtful  cases  also,  when  a  partial  per- 
foration only  is  suspected,  a  surgeon  should  be  called  at  once, 
to  share  the  responsibility  of  deciding  upon  the  treatment  to  be 
followed.  It  is  not  possible  to  say  that  a  partial  perforation 
may  not  soon  burst  through  the  plastic  adhesions  and  set  up  a 
general  peritonitis.  If  no  operation  is  performed  in  cases  of 
partial  perforation,  the  pain  of  the  resulting  adhesions  may  be 
somewhat  relieved  by  massage  (after  the  case  has  become 
chronic)  and  sometimes  by  percutaneous  galvanism;  but  late 
surgery  is  often  indicated  to  relieve  the  symptoms — pain,  func- 
tional disturbance,  and  at  times  obstruction — caused  by  these 
adhesions. 

Cicatricial  contraction  of  either  orifice  of  the  stomach  con- 
verts the  case  into  a  surgical  one,  and  operative  intervention 
should  then  be  insisted  upon  as  indispensable.  When  this  is 
declined,  something  can  be  done  in  moderate  strictures  of  the 
pylorus  producing  gastric  dilatation,  by  lavage  daily  or  even 
twice  daily  (Riegel),  and  by  controlling  the  hyperacidity. 
Full  doses  of  sodium  bicarbonate,  or,  sometimes  better  yet,  a 


558  THE    GASTRO-INTESTINAL    CLINIC 

mixture  of  other  alkalies,  as  magnesia  usta,  prepared  chalk, 
and  bismuth  subnitrate,  so  combined  as  to  keep  the  bowels  in  a 
proper  condition  of  openness  without  looseness,  will  in  most 
cases  effect  this,  and  thereby  generally  lessen  the  dilatation  by 
preventing  spasmodic  closure  of  the  pylorus. 

When  cancer  develops  in  an  ulcer  surgery  is  demanded. 

Erosions  of  the  Stomach. — A  pathologic  condition  of  the 
gastric  mucosa  characterized  by  pain,  weakness,  emaciation, 
and  sometimes  hemorrhages  which  may  be  severe,  showing  in 
the  lavage  water  shreds  of  membrane,  has  been  described  by 
numerous  writers,  and  been  variously  classified.  It  presents 
analogies  both  to  chronic  gastritis  and  to  ulcer,  but  does  not 
correspond  entirely  with  either  in  its  symptomatology.  It  is 
relatively  very  much  less  frequent  than  either,  and  quite  rare 
in  a  severe  form.  Its  pathology  is  not  understood.  Einhorn 
classifies  this  as  a  separate  disease  which  he  considers  to  have 
resulted  from  chronic  gastritis.  The  condition  would  appear 
to  be  one  of  superficial  exfoliation  of  the  upper  layer  of  the 
mucosa,  the  name  Erosions  of  the  Stomach  implying  that  raw 
surfaces  are  left  in  places  which  account  for  the  pain  after 
taking  food,  as  well  as  for  the  occasional  hemorrhage. 

Hemmeter,  who  does  not  consider  erosions  of  the  stomach 
as  a  separate  disease,  finds  this  condition  generally  character- 
ized by  hyperacidity,  and  finds  that  it  yields  often  to  a  milk 
diet.  Einhorn  has  observed  it  in  association  with  both  an  ex- 
cessive and  deficient  secretion  of  HCl,  but  more  frequently  the 
latter.  Riegel  makes  no  special  mention  of  it,  but  describes  a 
similar  condition  in  his  account  of  the  complications  of  gastri- 
tis, while  Stockton,  in  a  note  to  the  American  Edition  of 
Riegel,  inclines  to  Einhorn's  view  of  the  trouble. 

The  treatment  of  this  condition  when  it  complicates  a  chronic 
gastric  catarrh,  should,  in  the  main,  be  the  same  as  for  ulcer, 
but  may  include  also  lavage  and  other  intragastric  methods 
which  would  be  unsafe  in  ulcer.  Einhorn  recommends  lavage 
and  spraying  with  a  o.  i  to  0.2  per  cent,  solution  of  nitrate  of 
silver;  also  intragastric  galvanization. 


LECTURE  LV 
ROUND    ULCER   OF    THE    DUODENUM 

Peptic  or  round  ulcer  of  the  duodenum  is  probably  less 
frequent  than  gastric  ulcer,  and  is  still  more  likely  than  the 
former  to  run  a  latent  course  until  a  severe  hemorrhage,  or 
even  perforation  and  general  peritonitis  call  attention  to  it. 
Mayo  finds  duodenal  ulcer  more  frequent  than  gastric,  and 
other  surgeons  report  a  high  ratio  of  duodenal  ulcer.  The 
probable  explanation  of  this  is  that  duodenal  ulcer  is  more 
likely  to  have  complications  demanding  surgery. 

Duodenal  ulcer  differs  from  gastric  ulcer  in  several  notable 
particulars.  The  former  is  more  common  in  men,  and  be- 
tween the  ages, of  20  and  60;  the  latter  in  women,  and  between 
the  ages  of  20  and  30.  Ulcer  of  the  duodenum  not  only  oftener 
runs  a  latent  course,  but  is  also  much  more  refractory  to 
treatment,  decidedly  more  liable  to  perforation  as  well  as  to 
obstructive  cicatricial  contraction,  and  in  consequence  is  a 
more  dangerous  disease  than  ulcer  of  the  stomach.  It  also 
occurs  relatively  often  in  infancy  and  childhood,  while  ulcer  of 
the  stomach  is  rarely  ever  encountered  under  the  age  of  10. 
Its  most  usual  site  is  at  the  upper  end  of  the  duodenum,  be- 
tween the  pylorus  and  the  opening  of  the  common  bile  duct 
and  pancreatic  duct.  Generally  it  is  quite  close  to  the  pylorus, 
though  it  sometimes  appears  lower  down,  and  exceptionally 
may  be  found  in  any  part  of  the  duodenum,  or  even  in  the 
upper  part  of  the  jejunum.  It  varies  in  size  from  that  of  a 
pea  to  that  of  a  twenty-five-cent  piece,  or  even,  exceptionally, 
to  that  of  a  dollar. 

.ffitiology  and  Pathology. — The  causes  and  histologic  pe- 
culiarities of  ulcer  here  are  practically  identical  with  those  of 

559 


560  THE    GASTRO-INTESTINAL    CLINIC 

gastric  ulcer,  except  that  extensive  burns  of  the  skin  may 
often  in  some  obscure  way  produce  the  former,  and  the  ulcers 
from  such  burns  are  usually  much  longer  than  broad  and  are 
jagged  in  outline.  Boas  mentions  also  as  possible  causes, 
freezing,  erysipelas,  septicaemia,  etc.  It  may  complicate 
nephritis.  Being  supposedly  dependent  upon  the  same 
digestive  action  of  the  gastric  juice  upon  mucosa  of  lowered 
vitality,  the  result  is  the  same — a  punched-out,  funnel-shaped 
ulcer,  usually  single,  though  sometimes  multiple,  extending 
down  through  the  submucosa  and  muscular  layer,  and  still 
more  frequently  than  when  in  the  stomach  perforating  with 
the  result  of  producing  either  adhesions  to  adjacent  viscera  or 
general  peritonitis.  Duodenal  ulcer  when  it  heals  is  likely  to 
produce  more  serious  results  from  scar  formation  than  when 
situated  in  any  part  of  the  stomach,  other  than  the  pylorus, 
because  the  duodenum  is  so  much  smaller  that  obstruction  of 
the  lumen  more  certainly  follows  cicatricial  contraction. 

The  Symptoms  of  Duodenal  Ulcer. — As  already  mentioned, 
there  may  be  no  symptoms  at  all,  and  such  a  latent  course  is 
far  more  frequent  in  this  than  in  gastric  ulcer.  The  symptoms 
when  present  are  very  similar  to  those  in  the  former  disease, 
and  yet  present  some  decided  differences.  There  is  likely  to  be 
the  same  burning  or  boring  pain,  but  instead  of  coming  on  di- 
rectly, or  within  a  very  short  time  after  food  has  been  taken, 
it  is  rarely  felt  until  at  the  end  of  two  to  four  hours,  and 
often  not  until  after  five  or  six  hours,  that  is,  not  until  the  con- 
tents of  the  stomach  at  the  termination  of  peptic  digestion, 
are  passing  into  the  duodenum.  The  pain  does  not,  as  a  rule, 
radiate  toward  the  back,  but  upward  or  downward.  The 
pain,  too,  is  not  increased  by  taking  more  food  or  alco- 
holic drinks  as  in  gastric  ulcer,  but  may  rather  be  helped  by 
these.  There  is  also  usually  tenderness  on  pressure,  but  it 
is  almost  uniformly  felt  to  the  right  of  the  middle  line  near  the 
lower  border  of  the  liver,  or  a  little  lower  down  in  the  right 
hypochondrium.  But  since  the  site  of  the  ulcer  is  usually 
very  near  the  pylorus,  and  the  latter  is  not  infrequently  much 


ROUXD    ULCER    OF    THE    DUODENUM  561 

displaced  downward,  the  situation  of  the  pain  and  tenderness 
may  be  changed  accordingly.  Vomiting  may  occur,  but  more 
rarely  than  in  gastric  ulcer.  Hemorrhage  is  quite  as  likely  to 
result,  but  when  it  does,  is  usually  different  from  that  seen  in 
ulcer  of  the  stomach,  in  one  very  important  respect  especially. 
That  is,  blood  is  rarely  vomited  without  at  the  same  time  some 
of  it  passing  off  by  the  bowels,  either  in  an  unchanged  or 
slightly  changed  form  or  as  melena,  w'hereas,  in  ulcer  of  the 
stomach  it  frequently  happens  that  all  the  blood  lost  is  vom- 
ited, none  being  left  to  escape  by  the  bowels.  And,  on  the 
other  hand,  it  is  much  more  common  in  duodenal  ulcer  to  find 
evidences  of  blood  in  the  stools  when  none  at  all  has  been 
vomited.  Exceptional  cases,  however,  have  been  reported  of 
duodenal  ulcer  in  wdiich  there  was  hematemesis  without  blood 
in  the  stools.  Another  feature  of  the  hemorrhage  in  these 
cases  is  that  when  hematemesis  occurs,  the  vomitus  wdll  at 
first  contain  nothing  but  food  remains  or  chyme,  and  then, 
later,  the  blood  will  come  up,  possibly  mixed  with  bile.  In  the 
hematemesis  of  gastric  ulcer  the  blood  is  likely  to  come  up  at 
once  W'ith  the  food  previously  taken.  This  is  a  highly  im- 
portant diagnostic  point.  The  bleedings  may  be  moderate  and 
recur  frequently  or  speedily  cause  death.  Ewald  insists  that 
according  to  his  experience  the  gastric  juice  in  duodenal  ulcer 
more  frequently  than  otherwise  shows  only  a  normal  or  sub- 
normal percentage  of  HCl,  instead  of  an  excess,  as  is  the  rule 
in  gastric  ulcer.  Boas  and  Einhorn  report  a  contrary  experi- 
ence, and  have  usually  seen  hyperchlorhydria  with  ulcer  of  the 
duodenum.  Attention  is  called  to  the  fact  that  it  is  precisely 
those  cases  which  have  been  wdthout  symptoms,  the  patients 
feeling  and  looking  well,  that  are  most  likely  to  develop  se- 
rious hemorrhage  or  perforation,  while  those  in  which  there 
have  been  long-continued  symptoms,  such  as  pain  after  food, 
tenderness  on  pressure,  etc.,  more  rarely  experience  such  ac- 
cidents. 

Constipation  very  often  coexists  wdth  duodenal  ulcer,  but 
perhaps  not  oftener  than  in  most  other  dyspeptic  troubles. 


562  THE    GASTRO-INTESTINAL    CLINIC 

Jaundice  is  a  somewhat  rare  symptom,  but  when  encountered 
is  very  significant  as  to  the  situation  of  the  lesion,  increasing 
the  probabiHties  that  any  existing  ulcer  is  in  the  duodenum, 
and  not  in  the  stomach. 

Diagnosis. — Notwithstanding  that  the  above  described 
symptoms  present  numerous  marked  differences  from  those 
found  in  ulcer  of  the  stomach,  it  is  often  difficult,  and  some- 
times impossible  to  decide  whether  the  ulcer  which  is  the  ob-. 
vious  cause  of  bleeding,  pain,  tenderness,  etc.,  is  situated  in 
the  stomach  or  intestine.  Whether  the  ulcer  is  just  above  or 
just  below  the  pyloric  opening  might  be  manifestly  at  ti^s 
very  hard  to  determine,  especially  when  the  stomach  is  small, 
and  lies  further  to  the  left  than  usual,  since  then,  an  ulcer  in 
the  upper  part  of  the  duodenum  might  produce  all  the  symp- 
toms and  signs  of  one  in  the  pyloric  part  of  the  stomach.  So, 
with  an  enlarged  stomach  or  one  much  displaced  downward 
and  to  the  right,  a  pyloric  ulcer  might  closely  simulate  one  in 
the  duodenum.     (For  Einhorn's  thread  test  see  Lecture  LIII.) 

Boas  has  experienced  the  greatest  difficulty  in  differentiating 
between  duodenal  ulcer  and  hyperchlorhydria.  In  both,  pain 
comes  on  two  to  four  hours  after  eating,  and  is  usually  re- 
lieved by  taking  more  food  or  alkalies.  The  pain  is  also 
often  referred  in  both,  chiefly  to  the  region  of  the  pylorus,  and 
there  may  be  even  in  hyperchlorhydria  some  sensitiveness  in 
the  same  region.  He  believes  that  frequently  in  such  cases  the 
diagnosis  cannot  be  made,  and  whenever  the  patients  do  not 
improve  speedily  upon  the  diet  suitable  for  hyperacidity,  he 
advocates  instituting  the  accepted  cure  for  ulcer  with  con- 
finement to  bed,  rectal  feeding,  etc.  For  the  rest,  the  differ- 
ential diagnosis  of  duodenal  ulcer  must  be  made  from  the 
crises  of  locomotor  ataxia,  gall-stones,  cancer,  and  sarcoma  or 
other  morbid  growths.  In  tabetic  crises  there  would  be  the 
usual  symptoms  of  tabes,  though  the  crises  may  be  among  the 
earliest  symptoms,  and  there  would  be  no  hemorrhage  or 
pain  on  pressure,  and  no  relation  generally  between  the  at- 
tacks of  pain  and  the  taking  of  food.     Some  forms  of  hepatic 


ROUND   ULCER   OF   THE  DUODENUM  563 

colic  are  at  times  accompanied  by  a  slight  passage  of  blood 
with  the  feces,  but  the  pain  in  these  cases  has  again  no  con- 
nection with  eating  or  drinking;  the  attacks  do  not  usually 
last  so  long  as  the  exacerbations  of  an  ulcer  and  the  pain  is 
generally  more  violent.  Jaundice  is  much  more  common  in  gall- 
stones, but  may  be  present  in  duodenal  ulcer,  as  a  result  of 
catarrhal  swelling,  etc.  Palpable  swelling  and  tenderness  of 
the  gall-bladder,  and  tenderness  and  enlargement  of  the  liver, 
point  rather  to  gall-stones.  A  right  posterior  point  of  tender- 
ness is  also  more  common  in  the  latter  disease.  Gall-bladder 
teiii^erness  is  best  elicited  by  pressing  the  ends  of  the  fingers 
upward  under  the  right  costal  arch  as  the  patient  takes  a  deep 
breath.  The  sensitive  gall-bladder  is  thus  forced  down  against 
the  fingers,  and  the  patient  will  wince  or  cry  out.  Ulcer  ten- 
derness, on  the  other  hand,  is  best  brought  out  by  pressure 
directly  backward  in  the  pyloric  or  duodenal  region.  When 
ulcer  is  suspected  palpation  should  be  very  gentle,  as  there  is 
danger  of  causing  perforation  or  hemorrhage.  Cancer  or  sar- 
coma of  any  of  the  structures  in  the  right  hypochondrium 
might  raise  some  doubt  in  any  case  which  has  been  only  a  short 
time  under  observation,  but  the  course  of  either  disease  is  so 
entirely  different  from  that  of  ulcer  that  the  diagnosis  could 
soon  be  positively  established.  Other  morbid  growths  in  the 
same  region  could  scarcely  mislead  you,  since  they  would  not 
be  painful  or  cause  hemorrhage  and  could  usually  be  palpated. 

Complications  and  Sequels. — Chief  among  these,  in  addition 
to  the  hemorrhage,  are  local  peritonitis  resuhing  in  adhesions 
to  adjacent  viscera  with  kinking,  displacements,  etc.,  causing 
possible  obstruction  of  the  bowels  and  gastrectasis,  general 
peritonitis  from  perforation,  cicatricial  contractions  narrowing 
the  lumen  of  the  gut  and  leading  to  dilatation  of  the  stomach; 
or  the  perforation  may  cause  fistulous  connections  between  the 
duodenum  and  any  of  the  neighboring  organs. 

Carcinomatous  degeneration  may  happen  in  duodenal  as  in 
gastric  ulcer,  but  fortunately  much  less  frequently,  as  excision 
is  almost  never  possible.     It  would  be  revealed  by  the  develop- 


564 


THE    GASTRO-INTESTINAL    CLINIC 


ment  of  the  usual  symptoms  of  malignancy,  including  a 
progressive  lowering  of  the  general  health,  more  steady  and 
continuous  pain,  cachexia,  etc.,  and  by  early  obstructive  symp- 
torps. 

Prognosis. — In  duodenal  ulcer  consequent  upon  burns  of 
the  skin,  the  prognosis  is  absolutely  bad,  there  having  been  no 
case  of  recovery  so  far  reported.     Medical  treatment  fails,  and 

c 


■% 


v,_,y 


Fig.  74. — Carcinomatous  ulcer  of  the  duodenum,  {a)  the  duodenal  ulcer, 
the  thickened  edges  of  which,  resembling  a  rampart,  are  the  seat  of  carci- 
nomatous infiltration  ;  {b)  transverse  section  of  the  thickened  and  infil- 
trated intestinal  wall  ;  {c)  pylorus,  which  is  also  thickened  ;  {d)  stomach. 
(From  "  Krankheiten  des  Darms  u.  des  Bauchfells,"  von  Prof.  Dr.  C. 
A.  Ewald.) 

the  condition  of  the  patient  does  not  usually  admit  of  opera- 
tive intervention.  In  other  ulcers  of  the  same  part  the  prog- 
nosis is  always  much  more  serious  than  in  those  of  the  stom- 
ach for  the  reasons  fully  stated  above. 

Treatment — In  the  main,  the  treatment  of  duodenal  ulcer 


ROUND    ULCER    OF    THE    DUODENUM  565 

should  follow  the  same  lines  as  that  of  gastric  ulcer.  Rest  in 
bed,  however,  and  the  withholding  of  all  food  and  of  disturb- 
ing medicine  by  the  mouth  are  more  imperative  than  in  the  case 
of  the  latter.  Full  doses  of  bismuth  should  be  administered  as 
directed  in  the  lecture  devoted  to  that  subject,  and  the  other 
remedies  therein  recommended,  including  hot  poultices,  are 
equally  applicable  here,  unless  the  tests  of  the  stomach  contents 
should  show  a  deficiency  of  HCl,  when  alkalies  need  not  be 
given.  Orthoform  in  5-  to  7-grain  doses  may  be  added  to  each 
dose  of  the  bismuth  when  there  is  much  pain. 

The  danger  of  hemorrhage,  perforation,  etc.,  being  greater 
than  in  gastric  ulcer,  and  the  results  of  such  accidents  more 
to  be  feared,  when  they  do  occur,  the  stomach  tube  ought  not 
to  be  used,  in  any  case  in  which  ulcer  of  the  duodenum  can  be 
reasonably  suspected,  except  on  a  patient  who  is  known  to  tol- 
erate it  well.  It  is  the  violent  efforts  of  gagging  and  vomiting 
which  are  to  be  feared. 

In  another  respect  the  course  of  procedure  is  different  from 
that  suitable  in  gastric  ulcer.  In  the  latter  disease,  non-opera- 
tive measures,  including  a  very  careful  diet  and  medicinal  and 
mechanical  therapeutics,  have  won  some  of  their  most  brilliant 
victories,  and  good  results  are  always  to  be  expected  from  such 
measures,  in  the  beginning  at  least;  but  in  duodenal  ulcer  the 
prognosis  being  much  less  favorable,  you  should  proceed  more 
cautiously  and  protect  both  your  own  reputation,  and  the  in- 
terests of  the  patient,  by  associating  with  you  at  the  outset  a 
competent  abdominal  surgeon.  Then  if  the  treatment  pre- 
scribed succeeds,  and  the  symptoms  promptly  subside,  well  and 
good;  but  if  "not,  the  surgeon  will  be  in  a  better  position  to 
afford  you  efficient  assistance,  than  if  suddenly  called  in  after 
a  serious  turn  in  the  case.  In  the  former  event,  continue  the 
rectal  feeding  for  one  or  two  weeks,  and  then  resume  feeding 
by  the  mouth  with  even  more  caution  than  was  advised  for  the 
treatment  of  gastric  ulcer.  If  you  should  be  so  fortunate  as 
to  secure  a  recovery  by  these,  or  by  any  means,  see  to  it  that 
the   patient   thereafter   so   orders   his   diet   and   way  of   liv- 


566  THE    GASTRO-INTESTINAL    CLINIC 

ing  generally  as  to  avoid  a  recurrence  of  such  a  dangerous 
condition,  and  this,  notwithstanding  the  varying  testimony 
upon  the  subject,  will  probably  be  best  accomplished  by  com- 
bating any  tendency  of  his  gastric  glands  to  secrete  HCl 
excessively.  For  practical  suggestions  on  this  subject,  see 
Lecture  LIV.,  under  the  head  of  the  prophylactic  treatment  of 
gastric  ulcer. 

If,  after  the  disappearance  of  the  symptoms  in  whole  or 
part,  there  should  be  a  return  of  them,  indicating  that  the 
ulcer  persists,  by  all  means  advise  operative  intervention  with- 
out further  delay.  In  the  event  of  perforation,  immediate 
operation  will  be  necessary.  In  these,  as  in  all  cases  in  which 
surgical  aid  is  likely  to  be  needed,  there  should  be  the  most 
cordial  co-operation  between  the  physician  or  physicians,  and 
the  surgeon.  The  life-saving  achievements  of  both  belong  to 
the  glory  of  the  profession. 


LECTURE  LVI 

TUBERCULAR    ULCERATIONS    IN    THE 
STOMACH    AND    INTESTINES 

Contrary  to  a  prevalent  impression,  there  is  often  present 
in  the  gastric  juice  an  excess  of  free  HCl  in  the  early  stages  of 
phthisis.  Numerous  observers  testify  that  digestive  derange- 
ments of  one  kind  or  another  are  in  a  considerable  proportion 
of  cases  the  first  symptoms  complained  of  in  conditions  which 
later  develop  the  usual  signs  of  tuberculosis  in  the  lungs  or 
elsewhere.  The  most  frequent  tuberculous  involvement  of  the 
stomach  is  by  miliary  tuberculosis.  In  such  cases  the  gastric 
mucosa  may  be  studded  with  tubercles.  But  true  tubercular  ul- 
ceration is  rare  in  the  stomach  at  any  stage,  especially  without 
a  similar  involvement  of  the  intestines.  This  is  probably  due  to 
the  fact  that  the  acid  of  the  gastric  juice  impairs  the  activity  of. 
the  tubercle  bacilli,  and  prevents  their  proliferation  when  swal- 
lowed with  the  sputum.  When  tubercular  ulcers  exist  in  the 
stomach,  the  symptoms  are  practically  the  same  as  those  of 
simple  peptic  ulcer,  and  the  treatment  may  be  the  same,  plus 
the  general  roborant  measures,  especially  hygienic  and  cli- 
matic, required  for  the  constitutional  condition.  The  absence 
of  free  HCl  in  cases  showing  the  usual  signs  and  symptoms  of 
gastric  ulcer  might  well  lead  you  to  suspect  a  tubercular  origin, 
especially  when  either  some  part  of  the  respiratory  tract  or  any 
region  of  the  body  presents  tubercular  lesions. 

Tubercular  Ulcers  of  the  Intestines. — The  same  holds  true 
for  ulcer  of  the  duodenum.  Neither  in  the  stomach,  nor  as  a 
rule  in  the  duodenum,  will  tubercular  ulcers  be  found  so  long 
as  there  is  regularly  a  normal  percentage  of  HCl  secreted  by 
the  gastric  glands,  and  it  is  probable  that  even  a  very  limited 

567 


568  THE    GASTRO-INTESTINAL    CLINIC 

secretion  of  the  same,  so  deficient  as  to  leave  no  surplus  in  the 
free  form,  may  yet  exert  such  an  inhibitory  effect  upon  the 
swallowed  bacilli  as  to  prevent  the  development  of  tuberculous 
?ilcers  in  these  regions. 

In  the  remainder  of  the  intestine  such  ulcers  more  com- 
monly occur,  especially,  according  to  Nothnagel,  Boas,  Pick, 
and  others,  in  the  lowest  part  of  the  ileum,  and  in  the  cecum, 
as  well  as  in  the  sigmoid  flexure  and  rectum,  where  there  is 
more  stagnation  of  the  feces  than  elsewhere.  Primary  tuber- 
culosis of  the  intestine  in  adults  is  exceptional,  resulting  then 
generally  from  infection  through  non-sterilized  milk  or  other 
uncooked  or  insufficiently  cooked  animal  foods.  It  is  more 
frequent  jn  young  infants,  and  to  a  much  less  extent  in  older 
children.  While  the  HCl  of  the  gastric  juice  usually  exerts  a 
sufficient  antiseptic  effect  to  protect  the  stomach  and  duo- 
denum, it  does  not  necessarily  kill  the  bacilli,  so  that  when  the 
food  containing  them  passes  on  into  parts  of  the  bowel,  the 
contents  of  which  are  alkaline,  a  favorable  culture  medium  is 
met  with,  and  infection  may  take  place. 

But,  except  in  young  children,  tuberculosis  of  the  intestine 
is  nearly  always  a  secondary  process,  the  source  of  infection 
being  as  a  rule  the  swallowed  sputum.  The  affection  is  then 
usually  characterized  by  diarrhea  as  well  as  the  familiar  symp- 
toms of  phthisis,  viz.,  cough,  profuse  expectoration,  emacia- 
tion, debility,  fever,  and  night  sweats.  Sometimes  palpation 
reveals  swollen  mesenteric  glands,  and  often  sensitive  areas 
over  the  lower  abdomen,  corresponding  to  the  sites  of  the 
ulcers.  Tubercular  ulcers  in  the  jejunum  or  upper  part  of  the 
ileum,  without  involvement  of  the  lower  bowel,  may  be  accom- 
panied by  constipation. 

Pathology. — The  standard  works  on  pathology  have  little 
or  nothing  to  say  of  tubercular  ulcer  of  the  stomach,  and  the 
reports  of  such  cases  in  medical  literature  do  not  for  the  most 
part  go  at  all  deeply  into  the  subject  of  their  pathology.  It  is 
believed,  however,  that  the  infection  usually  comes  through 
the  circulation,  and  not  directly  from  food  or  sputum  infected 


TUBERCULAR    ULCERATIONS    IN    THE    STOMACH  569 

with  the  bacilh.  The  ulcers  may  be  either  single  or  multiple, 
and  of  any  size  from  that  of  a  pinhead  to  that  of  a  silver  dol- 
lar. They  rarely  extend  below  the  submucosa.  Various 
authors  are  of  the  opinion  that  previously  existing  ulcers  or 
erosions  become  the  seats  of  the  tuberculous  process,  the  loss 
of  substance,  as  in  other  cases,  facilitating  infection.  Tubercle 
bacilli  may  usually  be  found  in  the  necrosed  tissue  lying  upon 
the  surface  of  the  ulcers  as  well  as  in  remains  of  the  glands. 

Tuherculous  ulcers  of  the  intestines  occur  very  much  more 
frequently  and  their  character  has  been  exhaustively  studied. 
They  have  been  found  in  from  50  to  70  per  cent,  of  all  ad- 
vanced cases  of  pulmonary  tuberculosis.  The  infection  is  be- 
lieved to  be  rarely  primary  except  in  infants,  but  as  a  rule 
secondary  resulting  from  the  bacilli  in  the  swallowed  sputum. 
The  usual  situation  of  such  ulcers,  according  to  Green,  is  the 
lower  end  of  the  ileum,  but  Ewald^  says  they  are  not  only  very 
common  in  the  ileo-cecal  region,  but  also  in  the  descending 
colon,  and  wherever  else  the  feces  most  stagnate.  Some  other 
writers  assert  that  such  ulcers  are  found  most  frequently  in 
the  rectum.  They  develop  from  miliary  tubercles  and  chiefly 
in  the  solitary  follicles  and  Peyer's  patches,  those  occurring  in 
the  former  being  usually  round,  and  those  in  the  latter,  oval  in 
form.  They  often  become  confluent,  and  may  then  produce  an 
extensive  loss  of  tissue.  They  frequently  perforate  the  walls  of 
the  intestine,  producing,  as  in  similar  perforations  elsewhere 
when  the  process  is  slow  and  adhesions  have  had  time  to  form, 
patches  of  local  peritonitis,  or  when  the  progress  has  been  more 
rapid,  a  direct  opening  into  the  peritoneal  cavity  with  a  re- 
sulting general  peritonitis.  Healing  of  tubercular  ulcers  is 
not  common,  but  when  it  does  occur,  is  likely  to  produce  ob- 
struction of  the  bowel  by  the  contraction. 

Symptomatology. — In  Lecture  LVIII.  on  Intestinal  Ulcers 
Generally,  you  will  find  described  with  sufficient  fullness  the 
symptoms  which  are  fairly  characteristic  of  any  kind  of  ulcera- 

'  Die  Krankheiten  des  Darmsu.  des  Bauchfells,  von  C.  A.  Ewald,  Berlin, 
T902. 


SyO  THE    GASTRO-INTESTINAL    CLINIC 

tion  in  the  intestines  anywhere,  especially  below  the  duodenum. 
The  round  ulcer  of  the  duodenum  has  some  features  peculiar 
to  itself.  Apart  from  the  general  symptoms  of  tuberculosis,  it 
woyld  usually  be  impossible  to  determine  from  any  local  symp- 
toms present  that  an  ulcerative  process  revealed  by  the  char- 
acter of  the  stools,  as  well  as  by  pain  and  tender  spots  over 
portions  of  the  bowel,  was  of  tubercular  origin  rather  than  due 
to  some  other  cause.  Bleeding  is  less  common  from  tubercular 
ulcers  than  from  those  arising  in  the  course  of  typhoid  fever  or 
dysentery,  but  this  is  equally  true  of  catarrhal  ulcers  of  the  intes- 
tine. Boas  cites  Girode  as  authority  for  the  statement  that 
the  stools  passed  in  intestinal  tuberculosis  are  often  of  a  brown- 
ish-black color,  similar  to  the  coffee-grounds  vomit  seen  in 
cancer  of  the  stomach,  and  reports  that  this  observation  has 
been  confirmed  by  his  own  experience,  though,  at  the  same 
time,  he  cautions  that  such  peculiar  stools  are  by  no  means 
always  to  be  considered  as  having  an  admixture  of  blood. 

Diagnosis. — The  constant  presence  of  abundant  tubercle 
bacilli  in  the  stools,  or  the  occasional  finding  of  even  small 
quantities  of  the  same  at  a  time  when  the  patient  was  not  hav- 
ing any  sputa  at  all,  would  render  it  very  probable  that  some 
form  of  tuberculosis  existed  somewhere  in  the  alimentary 
canal,  especially  if  the  same  findings  should  persist  after  the 
patient  had  been  placed  upon  a  strictly  vegetable  diet  so  as  to 
exclude  the  possibility  of  the  bacilli  having  been  ingested  with 
tuberculous  meat,  milk,  or  other  infected  animal  food.  Gen- 
erally speaking,  however,  the  surest  evidence  that  an  intestinal 
ulceration  was  of  tubercular  origin  would  be  the  coexistence 
of  the  symptoms  and  signs  of  tuberculosis  elsewhere  in  the 
body;  and  if  at  the  same  time  numerous  bacilli  were  regularly 
found  in  the  evacuations,  the  diagnosis  might  be  considered 
established. 

The  ttihercuUn  test  should  be  resorted  to  in  any  doubtful 
case  in  which  there  is  a  strong  suspicion  of  primary  intestinal 
tuberculosis,  since  in  this  way  only  can  the  diagnosis  be  cer- 
tainly made,  and  you  may  now  accept  it  as  definitely  decided 


TUBERCULAR    ULCERATIONS    IN    THE    STOMACH  571 

that  this  is  not  only  a  reliable,  but  a  perfectly  safe  test  when 
properly  carried  out. 

Several  methods  of  making  the  test  are  now  in  common  use : 
Calmette's  ocular  test  consists  in  the  dropping  of  a  small 
amount  of  tuberculin  upon  the  conjunctiva  of  one  eye  of  the 
patient.  The  prompt  development  of  a  more  or  less  marked 
conjunctivitis  in  this  eye  constitutes  a  positive  reaction.  The 
test  is  quite  delicate,  but  dangerous.  Numerous  cases  of  seri- 
ous destructive  inflammation  have  been  reported.  The  method 
would  best  be  abandoned.  Von  Pirquet's  skin  test  is  consid- 
ered safe,  and  is  fairly  delicate :  the  skin  is  scarified  in  one  or 
two  places,  just  deeply  enough  to  avoid  drawing  blood,  the 
scarification  being  done  through  a  drop  of  diluted  or  strong 
tuberculin  previously  placed  upon  the  skin.  A  control  scarifica- 
tion is  made  with  a  clean  instrument  close  by.  In  twenty-four 
to  forty-eight  hours,  usually,  a  hyperemic  areola  forms  about 
the  scarifications  when  the  test  is  positive,  the  control  scarifica- 
tion showing  no  areola.  Moro's  test  is  made  by  rubbing  a 
small  bit  of  tuberculin  ointment  into  the  patient's  skin.  When 
positive,  an  eruption  of  papules,  vesicles  or  possibly  pustules, 
ensues.  The  skin  should  be  thoroughly  cleansed  with  ether  be- 
fore these  tests. 

The  subcutaneous  test  has  been  largely  supplanted  by  the 
foregoing,  but  is  still  used  and  is  safe  in  skilled  hands.  The 
beginning  dose  must  be  very  minute.  If  no  reaction  follows, 
it  is  customary  to  repeat  the  injection,  giving  twice  the  amount, 
and  to  give  a  third  still  larger  injection  if  necessary. 

The  reaction  after  a  sufficient  dose  is  generally  both  local 
and  general.  The  latter  is  shown  by  a  rise  of  from  i  to  2 
degrees  in  the  temperature  at  the  corresponding  times  of  the 
day,  together  with  lassitude  and  more  or  less  vague  distress, 
including  often  headache  and  sleeplessness.  The  local  reac- 
tion consists  usually  of  pain  and  tenderness  in  the  affected 
parts,  or  if  these  symptoms  existed  before,  they  are  much  in- 
tensified. If  there  be  a  lesion  in  the  lung,  there  are  rales  and 
disturbed  respiratory  rhythm  where  nothing  of  the  kind  may 


572  THE    GASTRO-INTESTINAL    CLINIC 

have  been  heard  before.  In  the  case  of  an  intestinal  ulcer  there 
should  be  markedly  increased  pain  and  tenderness,  with  pos- 
sibly an  increased  looseness  of  the  bowels. 

Prognosis. — Secondary  tuberculosis  of  the  intestine  is  prac- 
tically a  hopeless  condition,  and,  as  a  rule,  therefore,  only  a 
palliative  treatment  is  possible.  But  the  infrequent  cases  of 
primary  tuberculosis  of  the  bowel  as  well  as  of  the  stomach, 
when  uncomplicated,  should  be  curable  if  properly  treated  be- 
fore the  vital  forces  have  been  seriously  impaired.  Then,  too, 
the  cases  in  which  incipient  tuberculosis  of  other  regions  first 
reveals  itself  by  symptoms  of  indigestion  are  to  be  considered. 
Hence  the  extreme  importance  of  making  the  diagnosis  at  the 
earliest  possible  moment.  Whenever  persistent  derangement 
of  either  the  gastric  or  intestinal  digestion  is  accompanied  by 
progressive  wasting,  and  even  a  slight  regular  or  frequent  rise 
of  temperature  after  midday,  tuberculosis  may  well  be  sus- 
pected, and  the  patient  should  be  given  the  benefit  of  the 
doubt  by  instituting  the  appropriate  treatment. 

Treatment. — When  there  is  stubborn  diarrhea  with  fetid 
stools  and  sensitiveness  upon  pressure  over  circumscribed  spots 
in  the  bowels,  ulceration  of  some  kind  is  to  be  feared,  and  there 
is  the  possibility,  at  least,  that  it  may  be  tubercular.  In  such  a 
case  involving  the  colon  the  diseased  process  should  be  attacked 
with  vigor  locally,  by  the  use  of  antiseptic  colon  douches,  one 
of  the  most  effective  of  which  you  will  find  to  be  a  solution  of 
carbolic  acid  in  glycerin,  i  to  8,  of  which  a  teaspoonful  may  be 
diluted  with  a  quart  of  water.  Of  this  solution  inject  far  up 
into  the  colon  i  to  2  quarts  every  other  day,  while  on  the  al- 
ternate day  the  bowel  is  flushed  out  with  a  normal  salt  so- 
lution. Such  simple  curative  measures  should  be  carried  out 
in  any  case,  provided  there  are  no  contra-indications,  since  they 
are  very  helpful  in  even  catarrhal  ulceration  of  the  intes- 
tines. 

But  my  own  experience  has  shown  that  carbolic  acid  or 
creosote  administered  in  any  considerable  dose,  either  by  the 
mouth  or  per  rectum,  will  greatly  stimulate  the  gastric  glands, 


TUBERCULAR    ULCERATIONS    IN    THE    STOMACH  573 

increasing-  decidedly  the  secretion  of  HCl,  so  that  in  the  consid- 
erable proportion  of  cases  of  early  tuberculosis  with  gastric  de- 
rangement, in  which  the  HCl  is  in  excess  or  at  least  fully  up 
to  normal,  such  remedies  cannot  be  given  without  the  risk  of 
a  marked  aggravation  of  the  indigestion,  or  even  producing  an 
acid  dyspepsia  where  none  existed  before.  These  are  the  cases 
in  which  cod-liver  oil,  even  in  pretty  full  doses,  is  well  borne 
and  acts  so  favorably,  and  the  explanation  is  furnished  by  ex- 
periments which  have  demonstrated  that  all  oils  and  fats,  in- 
cluding butter,  tend  to  lessen  the  secretion  of  HCl.  The 
creosote  treatment,  and  the  use  of  carbolic  acid  per  rectum,  suit 
best  in  the  cases  in  which  the  HCl  secretion  is  much  below  the 
normal,  but  even  then,  if  there  be  chronic  gastritis  present,  full 
doses  by  the  mouth  are  likely  to  disagree. 

The  Tuberculin  Treatment — My  observations  as  consulting 
gastro-enterologist  at  the  Pottenger  Sanatorium  for  Diseases  of 
the  Throat  and  Lungs  during  a  period  of  four  years  have  con- 
vinced me  that  some  of  the  preparations  of  tuberculin  have,  in 
the  most  skillful  hands,  increased  decidedly  the  proportion  of 
obtainable  cures  in  uncomplicated  tuberculosis  of  the  lungs  as 
well  as  in  some  other  tuberculous  affections.  Dr.  F.  M.  Pot- 
tenger, director  of  the  above  mentioned  institution,  and  a 
recognized  expert  in  the  use  of  the  tuberculins,  employs  some 
one  of  these  preparations  in  most  of  his  cases,  selecting  that 
one  which  has  proved  most  helpful  in  his  large  experience  un- 
der like  conditions.  Of  Von  Ruck's  watery  extract  he  gives 
usually,  at  first,  doses  of  .001  to  .01 ;  his  beginning  dose  of 
Koch's  old  tuberculin  is  .001 ;  of  tuberculin  Denys  it  is  .0001  ; 
of  tuberculin  R,  it  is  .001  to  .002  of  the  solid  substance. 

The  following  extract  from  Dr.  Pottenger's  article  on  the 
Treatment  of  Tuberculosis  just  prepared  for  Hare's  Modern 
Treatment  affords  in  brief  a  fair  idea  of  his  views  as  to  the 
management  of  the  remedy  under  consideration: 

Dr.  Pottenger's  Method ~"  In  general,  however,  I  would 

suggest  the  following  as  a  safe  plan  for  the  administration  of 
tuberculin.     First,  no  matter  what  preparation  is  given,  begin 


574  THE    GASTRO-INTESTINAL    CLINIC 

with  a  dose  so  small  that  it  is  practically  certain  no  reaction 
will  be  produced.  This  dose,  of  course,  will  vary  materially 
accbrding  to  the  preparation  used  and  according  to  the  condi- 
tion of  the  patient.  Second,  always  keep  the  dose  short  of  pro- 
ducing a  general  reaction.  The  patient  who  has  very  slight 
S3aTiptoms  of  tuberculosis  is  more  apt  to  react  than  one  who 
has  more  marked  symptoms.  I  usually  begin  to  treat  patients 
who  are  extremely  nervous,  and  those  who  have  had  recent  ad- 
vances in  their  disease,  also  those  who  are  inclined  to  run  a 
temperature,  and  those  whose  reactive  powers  are  low,  with 
smaller  doses  than  I  do  others.  I  also  give  smaller  doses  to 
young  individuals  than  I  would  do  to  older  ones. 

"If  the  first  dose  is  borne  well  the  dosage  can  usually  be  in- 
creased as  follows  : — i  -2-3-4-5-6-7-8-9-10-15-20- 
30  -  40  -  50  -  etc. !  The  same  preparations  in  careful  and  ex- 
perienced hands  can  be  advanced  much  faster  than  in  inex- 
perienced hands.  If  one  is  to  err  in  dosage  let  it  be  on  the 
side  of  advancing  too  slowly  rather  than  too  rapidly.  The  in- 
tervals of  dosage  should  be  gradually  increased  as  the  dose  be- 
comes larger.  My  custom  has  been  to  begin  with  a  small  dose, 
administering  it  every  day  or,  more  commonly,  every  second 
day,  and  then  increasing  the  intervals  so  that,  by  the  time  the 
large  doses  are  given,  the  interval  has  been  increased  to  from 
7  to  10  days,  according  to  the  preparation  of  tuberculin  used. 
I  consider  it  very  important  in  beginning  the  administration  of 
tuberculin  to  increase  the  dosage  as  rapidly  as  the  patient  will 
bear  it.  By  increasing  the  amount  of  tuberculin  rapidly,  the 
tolerance  of  the  patient  is  materially  increased,  and  the  danger 
of  hypersensibility  is  decreased.  I  have  noticed  many  pa- 
tients who  have  been  treated  by  small  doses,  given  at  infrequent 
intervals,  who  finally  developed  a  state  of  hypersensibility 
which  manifested  itself  by  either  a  local  or  temperature  reac- 
tion every  time  a  dose  is  given.  Very  often  this  is  interpreted 
to  mean  that  the  patient  bears  tuberculin  very  poorly.  The 
proper  interpretation  to  my  mind  is,  that  the  patient  has  been 
treated  in  a  faulty  manner  and  has  become  hypersensitive  in- 


TUBERCULAR    ULCER.\TIONS    IN     THE    STOMACH  575 

stead  of  tolerant  to  the  remedy.  Such  patients  can  usually  be 
treated  successfully  by  changing  to  another  preparation  of 
tuberculin  and  increasing  the  dose  rapidly." 

Hygienic  and  Climatic  Measures,  etc. — In  the  treatment  of 
tuberculosis  of  the  gastro-intestinal  tract,  most  of  the  usual 
modern  methods  are  applicable,  especially  the  hygienic,  cli- 
matic, etc.  These  include  a  residence  in  a  healthy  climate, 
where  the  air  is  as  pure  as  possible  and  not  too  moist.  Sun- 
shine is  most  important,  and  when  practicable,  a  considerable 
elevation  is  of  undoubted  advantage  to  the  majority  of  cases. 
But  of  even  more  importance  than  the  choice  of  any  particular 
climate  is  the  indispensable  condition  that  the  patient  shall  be 
kept  out  of  doors  substantially  all  the  time,  even  at  night, 
when  possible,  properly  clothed  to  prevent  chilling  and  pro- 
tected from  rain  or  high  cold  winds.  When  there  is  fever,  a 
recumbent  position  should  be  maintained  out  of  doors,  and 
complete  rest  is  then  desirable.  It  is  the  oxygen  of  a  pure,  un- 
contaminated  air  that  is  probably  the  most  valuable  curative 
agent  we  have  £or  tuberculosis.  The  diet  should  be  suited  to 
the  condition  of  the  digestive  organs,  but  as  abundant  and 
nourishing  as  practicable.  By  practicable  here  I  mean  as  much 
as  the  patient  can  be  made  to  digest,  oxidize,  and  assimilate. 
In  a  paper  read  before  the  American  Climatological  Associa- 
tion, in  1894/  I  maintained  that  to  force  upon  tuberculous  pa- 
tients an  excess  of  food  beyond  that  which  can  be  oxygenated, 
can  only  work  injury  in  the  long  run;  that  there  is  a  direct 
ratio  between  the  amount  of  oxygen  consumed  in  the  system 
(wdiich  is  largely  increased  by  both  exposure  to  pure  outdoor 
air  and  by  exercise)  and  the  amount  of  food  that  can  be  safely 
and  helpfully  ingested.  This  statement  was  acquiesced  in  by 
the  distinguished  speakers  who  discussed  the  paper,  and  it  has 
not  been  since  disputed. 

Only  a  patient,  unwearying  study  of  each  case  by  itself,  with 
the  help  of  occasional  tests  of  the  stomach  contents,  frequent 

iThe  Ratio  which  Alimentation  Should  Bear  to  Oxygenation  in  Disease 
of  the  Lungs,  Transactions  American  Climatological  Association,  1894. 


5/6  THE    GASTRO-INTESTINAL    CLINIC 

analyses  of  the  urine,  a  study  of  the  blood,  and  in  some  cases 
chemical  and  microscopic  examinations  of  the  feces,  can  enable 
you  to  adapt  to  the  varying  conditions  the  diet  both  in  quality 
and, quantity,  so  as  to  bring  up  the  nutrition  to  the  highest  pos- 
sible point.  Medicines  by  the  mouth  need  to  be  administered 
with  much  discretion.  This  is  the  rock  upon  which  some  good 
physicians  split  in  managing  tuberculosis.  Not  enough  atten- 
tion is  paid  to  the  reaction  of  the  digestive  organs  to  the  reme- 
dies administered.  Many  cases  would  do  better  without  any 
drugs  at  all  than  with  such  as  are  commonly  given,  and  in  the 
usual  doses;  i-  or  2-drop  doses  of  Fowler's  solution  of  arsenic 
or  of  creosote  suit  most  cases  well,  though  I  have  seen  some 
with  a  weak,  irritable  stomach  in  which  tablets  containing  i-io 
drop  of  creosote  acted  most  favorably;  but  when  there  is  no  ex- 
cess of  HCl,  moderately  full  doses  of  the  same  remedies  often 
do  good.  The  same  may  be  said  of  the  hypophosphites,  glyc- 
erophosphates, strychnine,  and  the  stronger  preparations  of 
iron.  They  all  disagree  in  the  usual  doses  when  the  gastric 
glands  are  in  an  excited  or  irritated  condition.  Cod-liver  oil, 
as  mentioned  above,  may  suit  well  w^hen  there  is  a  normal  or 
excessive  percentage  of  HCl  in  the  stomach,  and  then  acts  best 
when  taken  about  two  hours  after  meals.  In  cases  of  deficient 
gastric  juice,  HCl  and  pepsin  should  be  administered,  and 
small  doses  of  creosote  or  carbolic  acid  may  then  be  added  to 
the  mixture,  when  needed  for  excessive  fermentation.  When 
the  ulcers  involve  the  small  intestine  so  that  antiseptic  or  astrin- 
gent remedies  cannot  be  hopefully  introduced  by  enema,  full 
doses  of  bismuth  by  the  mouth  with  ichthalbin  or  tannalbin,  or 
tannigen,  in  combination,  or  pills  of  silver  nitrate  with  bis- 
muth and  opium  will  usually  assist  in  controlling  the  diarrhea, 
at  least  temporarily.  With  the  exception  of  the  opium,  the 
same  remedies  may  often  be  continued  for  weeks  at  a  time, 
with  some  hope  of  exerting  a  favorable  influence  upon  the 
ulceration. 

Hydrotherapeutic  measures,  especially  the  tonic  use  of  cold 
water,   as  in  sponge  baths,   cool  or  cold  affusions,   etc.,   are 


TUBERCULAR    ULCERATIONS    IN     THE    STOMACH  577 

often  very  useful.  Breathing  exercises  and  gymnastics  to  ex- 
pand the  chest,  and  for  the  development  of  the  trunk  muscles 
generally,  are  excellent ;  horseback  riding  is  most  valuable,  and 
for  those  having  a  good  circulation,  cautious  bicycle  riding  and 
mountain  climbing  are  to  be  recommended. 

Patients  should  be  under  the  constant  watchful  care  of  a 
physician  until  well  advanced  in  convalescence,  and  be  cau- 
tioned especially  against  excess  of  every  kind. 

In  certain  selected  cases  of  tuberculosis  of  the  intestine  with- 
out a  serious  involvement  of  other  organs,  surgery  may  now 
be  resorted  to  hopefully.  In  the  International  Medical  Maga- 
zine for  November,  1899,  there  was  published  an  abstract  of 
an  interesting  paper  by  Mayo,  giving  the  history  of  seven  such 
cases  operated  on,  with  one  death,  the  others  having  been 
cured. 


LECTURE  LVII 

SYPHILIS    OF    THE    STOMACH    AND 
INTESTINES^ 

A  MAJORITY  of  authorities  on  diseases  of  the  stomach  make 
no  mention  whatever  of  syphihs;  and  in  truth  it  is  not  fre- 
quently encountered  in  practice.  Perhaps  it  would  be  more 
correct  to  say  that  the  disease  is  not  frequently  diagnosticated. 
Every  physician  with  a  large  practice  doubtless  meets  with 
cases  of  gastric  syphilis,  but  to  search  by  exact  methods  for 
the  various  diseases  and  disorders  of  the  stomach  has  not  yet 
become  the  rule,  so  that  the  true  nature  of  these  is  very  fre- 
c[uently  overlooked.  Syphilitic  affections,  even  when  existing, 
therefore,  are  not  often  recognized. 

In  any  case  in  which  there  are  undoubted  syphilitic  lesions  in 
the  liver  or  elsewhere,  we  may  well  suspect  that  it  has  a  luetic 
origin,  and  should  then  have  had  made  one  or  both  of  the  now 
available  diagnostic  tests  for  syphilis — a  microscopic  examina- 
tion of  the  blood  for  the  Spirochaeta  pallida  or  the  Wasser- 
mann  serum  test,  both  of  which  are  accepted  as  of  value,  espe- 
cially the  former.  The  finding  of  the  spirochetes  in  any  case  is 
generally  conceded  to  be  proof  positive  of  a  syphilitic  infection. - 

lA  part  of  this  lecture  appeared  as  the  author's  contribution  to  Syphilis; 
a  Symposium;  New  York,  E.  B.  Treat  &  Co.,  1902. 

2The  spirochetes  are  in  the  form  of  slender  spirals  like  a  corkscrew. 
Scholtz  thus  describes  a  method  of  staining  them  :  A  small  drop  of  the 
serum  on  the  slide  is  mixed  with  a  small  drop  of  distilled  water  and  a  small 
drop  of  the  mixture  is  transferred  to  another  slide.  Half  this  amount  of 
India  ink  is  then  added  and  mixed  and  spread  out  over  the  slide  with  the 
edge  of  another;  the  material  is  then  dry  and  ready  to  be  examined  in 
half  a  minute.  The  objects  in  the  field  are  comparatively  colorless  against 
a  dark  background.  (Abs.iny.  A.  M.  A.  of  Mar.  12,  1910,  from  Deutsche 
Med.  Woch.    (Berlin)  of  Feb.  3,  1910  ;  No.  5.) 

578 


SYPHILIS   OF   THE   STOMACH  579 

The  serum  test  sometimes,  though  rarely,  reacts  to  advanced 
cases  of  carcinoma,  tuberculosis  and  some  acute  conditions,  but 
a  positive  reaction,  especially  in  the  absence  of  the  diseases  just 
named,  would  warrant  you  in  instituting  anti-syphilitic  treat- 
ment. 

It  is  possible  that  we  may  have  a  syphilitic  chronic  gastritis, 
though  this  is  questionable.  It  is  well  established  that  there 
may  be  syphilitic  ulcers  in  the  stomach,  and  syphilitic  neo- 
plasms or  infiltrations  in  the  same  viscus,  involving  any  part 
of  the  organ,  especially  the  pylorus.  Very  exceptionally,  also, 
hemorrhage  of  supposed  syphilitic  origin,  but  not  dependent 
upon  ulcer,  may  take  place  in  the  stomach. 

Syphilitic  Chronic  Gastritis. — There  has  existed  consider- 
able doubt  whether  pathologically  the  frequent  cases  of  chronic 
gastritis  encountered  in  patients  who  are  affected  with  syphilis 
are  really  different  from  the  similar  forms  of  gastric  inflam- 
matory processes  due  to  other  causes.  IMost  authors  do  not 
admit  that  gastritis  can  result  directly  from  a  syphilitic  infec- 
tion. Secondary-  results  of  the  obstruction  of  the  portal  cir- 
culation caused  by  syphilis  certainly  occur  in  the  stomach. 
Hemmeter  and  Stokes  ^  have  reported  a  case  of  chronic  hyper- 
trophic gastritis  in  a  syphilitic  patient  who  was  operated  for 
stenosis  of  the  pylorus,  resulting  from  hyperplasia  as  deter- 
mined afterward  by  an  autopsy.  The  latter  showed  further 
a  marked  thickening  of  the  gastric  walls  in  various  parts  by 
a  characteristic  luetic  infiltration,  and  also  a  localized  sub- 
hepatic abscess.  The  patient  had  been  infected  with  S3'philis 
two  years  before  admission  to  the  hospital,  and  had  been  dys- 
peptic before  that.  His  symptoms,  while  under  observation, 
were  those  of  pyloric  stenosis — pain  or  discomfort  and  vomit- 
ing, especially  after  solid  food,  relieved  by  lavage.  The  usual 
tests  showed  the  absence  of  free  HCl  and  the  gastric  ferments. 
There  were  numerous  manifest  lesions  of  syphilis  elsewhere  in 
his  body.     Hemmeter  holds  that  "  if  characteristic  syphilitic 

ij.  C.  Hemmeter  and  W.  R.  Stokes,  Archiv  f.  Verdauungskr.,  B. 
VIIL,  Heft  4  and  5. 


580  THE    GASTRO-INTESTINAL    CLINIC 

lesions  exist  in  the  liver,  kidneys,  spleen,  pancreas,  or  intes- 
tines, the  chronic  gastritis  should  be  attributed  to  syphilis."  ^ 
He  believes  further  that,  "  in  tertiary  syphilis  the  remarkable 
malnutrition  is  due  to  a  chronic  gastritis,"  which  appears  very 
likely  to  be  true.  The  former  statement  seems  open  to  ques- 
tion. The  syphilitic  form  may  resemble  closely  the  ordinary 
chronic  gastritis,  showing  no  difference  pathologically  any 
more  than  symptomatically,  except  possibly,  the  greater 
amount  of  small  round-cell  infiltration.  In  some  cases,  how- 
ever, there  will  be  found  gummata,  or  possibly  gummatous 
ulcers  when  the  disease  has  progressed  to  the  tertiary  stage. 
The  diagnosis  will  turn  upon  the  results  of  the  tests  and  of  the 
treatment.  If  the  disease  yields  to  the  usual  methods  of 
treating  chronic  gastritis,  it  is  not  likely  to  be  syphilitic.  Per- 
sonally, I  doubt  that  a  true  primary  syphilitic  gastritis  ever 
occurs. 

Einhorn  -  believes  that  in  the  secondary  stage  of  syphilis, 
"  the  digestive  disturbances  are  attributable  to  the  constitu- 
tional condition,  to  the  fever,  etc.,  and  hence  are  to  be  re- 
garded as  concomitant  phenomena  of  the  original  disease  with- 
out any  special  involvement  of  the  stomach,"  but  considers  the 
gastric  affections  in  the  tertiary  stage  as  anatomic  processes  of 
a  true  syphilitic  character.  He  further  states  that  probably  in 
a  majority  of  the  cases  in  which  syphilitic  persons  suffer  from 
diseases  of  the  digestive  tract,  there  is  not  "  any  connection 
between  the  latter  and  the  antecedent  lues." 

Syphilitic  Gastric  Ulcer. — There  can  be  no  question  as  to 
the  fact  that  syphilis  occasionally  causes  gastric  ulcer.  Large 
numbers  of  cases  have  been  reported  in  medical  literature 
which  leave  no  room  for  doubt  on  this  point. 

While  the  authorities  do  not  agree  as  to  the  comparative 
frequency  of  syphilitic  ulcer  of  the  stomach,  the  following 
conclusions  seem  warranted : 

1  J.  C.  Hemmeter,  "  Diseases  of  the  Stomach,"  second  edition,  p.  597, 
Philadelphia,  igoo. 

2  Max  Einhorn,  "  Prog.  Med.,"  vol.  iv.,  1900,  p.  35. 


SYPHILIS    OF    THE    STOMACH  581 

(i)  Many  gastric  ulcers  occurring  in  persons  who  were 
manifestly  or  demonstrably  syphilitic  in  other  ways  may  be 
presumed  to  have  been  of  luetic  origin. 

(2)  These  had  been  in  most  cases  treated  previously  by 
the  methods  usually  successful  in  relieving,  if  not  curing, 
simple  round  ulcer  of  the  stomach,  without  improvement. 

(3)  They  respond  promptly  and  rapidly  to  antisyphilitic 
treatment.  In  numbers  of  cases,  too,  post-mortem  examina- 
tions have  revealed  gummata  and  gummatous  infiltrations  in 
the  same  stomachs,  and  in  some  instances  the  ulcers  had  evi- 
dently resulted  from  the  breaking  down  of  gummata. 

Stockton^  cites  the  case  reported  by  E.  Frankel,  of  a  man, 
aged  47,  who  died  from  perforative  peritonitis  after  suffering 
seven  years  from  subjective  gastric  symptoms,  with  an  ab- 
sence of  free  HCl.  Thirteen  ulcers  were  found  in  his  stom- 
ach, besides  many  in  the  intestines,  of  which  eighteen  had 
perforated.  The  histologic  examination  showed  the  case  to 
have  been  syphilis.  Stockton  also  cites  the  views,  of  Dieula- 
foy,-  who  has  studied  this  subject  somewhat  exhaustively. 
The  latter  summed  up  his  conclusions  as  follows : 

"  ( I )  Syphilis  of  the  stomach  is  not  as  infrequent  as  might 
be  thought. 

"  (2)  Syphilitic  lesions  of  the  stomach  occur  in  various 
forms,  hemorrhagic  erosions,  ecchymoses  of  the  mucous  mem- 
brane, gummatous  infiltrations  of  the  submucosa,  gumma- 
tous plaques,  circumscribed  gummata,  gummatous  ulcerations 
and  their  resultant  scars.  It  is  probable  that  here,  as  in  other 
losses  of  substance  of  the  stomach,  the  gastric  juice  augments 
this  ulcerative  process. 

"  (3)    The  symptoms  of  syphilitic  ulceration  of  the  stonir 

ach  may  resemble  completely  those  of  simple  gastric  ulcer; 

pains  over  the  ensiform  process,  besides  backache,  intolerance 

of  the  stomach,   vomiting  of  food,   small  and   large  gastric 

hemorrhages,  melena,  and  marked  emaciation. 

■■  "  Progressive  Medicine,"  vol.  iv.,  1899,  p.  34. 

"^  Bulletin  Med.,  1899,  No.  40.    Quoted  also  by  Einhorn  in  Phila.   Med. 
Jour.,  of  February  3,  igoo. 


582  THE    GASTRO-IXTESTINAL    CLINIC 

"  (4)  Xone  of  these  symptoms  (alone)  permits  us  to  as- 
sume the  syphihtic  nature  of  the  stomach  lesions.  As  soon  as 
the  signs  of  a  simple  gastric  ulcer  occur  in  a  syphilitic  person, 
we»  are  warranted  in  suspecting  the  syphilitic  nature  of  the 
stomach  lesion. 

"  (5)  ^^  e  should  never,  therefore,  neglect  to  seek  in  a  pa- 
tient presenting  symptoms  of  gastric  ulcer,  for  a  possible  ante- 
cedent history  of  syphilis. 

"  (6)  In  the  latter  case  an  appropriate  treatment  with  mer- 
curial preparations  and  potassium  iodide  must  be  at  once  ini- 
tiated. 

"  (7)  The  recognition  of  syphilis  as  a  cause  of  gastric 
ulcer  is  the  more  important,  since  this  enables  us  to  cure  pa- 
tients who  otherwise  might  have  been  subjected  to  surgical 
intervention." 

With  our  present  light,  Dieulafoy's  conclusion  6  would 
doubtless  be  modified,  so  as  to  require  one  of  the  tests  for 
syphilis  to  be  made  before  instituting  treatment  therefor. 

Stockton,  in  the  same  article,  refers  to  contributions  by 
Allen  Jones  and  others  concerning  gastralgia  of  apparent 
syphilitic  origin,  and  in  view  of  recent  developments  showing 
the  frecjuency  of  gummata,  luetic  infiltrations,  etc.,  in  the 
stomach,  inclines  to  the  belief  that  the  gastralgia  of  syphilis 
may  "  more  frequently  depend  upon  a  lesion  than  has  been 
supposed." 

Cases  of  S3^philitic  gastric  ulcer,  thus,  do  not  seem  to  pre- 
sent any  particular  symptoms  different  from  those  occurring 
in  ordinary  gastric  ulcer.  The  patients  have,  as  a  rule,  acute 
pain  after  taking  solid  food,  frequently  vomit  the  stomach- 
contents,  and  in  a  considerable  proportion  of  cases  may  pre- 
sent the  usual  signs  of  hemorrhage,  with  often  perforation. 

Syphilitic  Ulcers  of  the  Intestines. — ]\Iost  authors  make  no 
mention  whatever  of  a  syphilitic  enteritis  or  colitis.  Among 
those  who  have  written  books  on  diseases  of  the  intestines, 
without  including  any  reference  to  such  an  affection,  are 
Ewald,    Nothnagel,    Penzoldt,    Boas,    and    Einhorn.     Since, 


SYPHILIS   OF   THE   STOMACH  583 

therefore,  it  is  at  least  questionable  whether  a  catarrhal  in- 
flammation in  any  part  of  the  alimentary  canal  can  be  due  di- 
rectly to  syphilitic  infection,  and  even  when  suspected  to  have 
such  an  origin  is  confessedly  not  to  be  differentiated  by  any 
histologic  phenomena  from  the  ordinary  chronic  catarrhal  in- 
flammation, I  shall  not  attempt  to  describe  to  you  a  syphilitic 
enteritis. 

Syphilitic  ulcers  do  occur  in  the  intestines,  though  rarely 
above  the  colon,  except  the  congenital  form  in  children.  They 
are  found  most  frequently  in  the  rectum.  Syphilitic  ulcers  of 
the  colon  are  commonly  the  result  of  gummata  which  have 
broken  down,  and  when  luetic  ulcers  appear  in  the  small  in- 
testines they  oftenest  arise  in  a  similar  manner;  but  they  may 
also  originate  from  ulceration  of  Peyer's  patches,  and  some- 
times be  produced  by  ulceration  or  a  specific  amyloid  degener- 
ation having  its  seat  in  the  intestinal  mucous  membrane. 

The  symptoms  of  specific  intestinal  ulcers,  as  in  other  forms 
of  intestinal  ulceration,  may  be  entirely  wanting,  or  they  may 
give  rise  to  pain,  -tenderness  on  pressure,  and  either  constipa- 
tion or  diarrhea;  blood,  pus,  and  shreds  of  necrosed  tissue  are 
also  discoverable  at  one  time  or  another  in  the  stools.  They 
differ  in  no  marked  way  from  those  of  other  intestinal  ulcers. 
The  diagnosis  cannot  usually  be  made  from  the  latter  by  the 
tests  already  mentioned,  except  from  the  signs  of  syphilis  else- 
where in  the  body  and  the  therapeutic  test. 

Syphilitic  Neoplasms  of  the  Gastro-intestinal  Tract. — These 
are  often  mistaken  for  carcinomas.  They  may  be  recognized 
by  palpation  when  they  have  attained  a  sufficient  size,  and  the 
existence  of  palpable  thickening  or  tumor  in  any  part  of  the 
abdomen  in  a  case  presenting  undoubted  luetic  lesions  else- 
where, should  at  once  lead  to  a  suspicion  of  a  syphilitic  growth. 

When  a  gummatous  infiltration  involves  the  pylorus,  we 
have  superadded,  of  course,  the  usual  symptoms  of  pyloric  ob- 
struction. That  is,  there  will  be  pain  and  vomiting,  followed 
later  usually  by  dilatation  of  the  stomach,  and  then  by  the 
usual  signs  of  retention,  including  the  vomiting,  at  intervals 


584  THE    GASTRO-INTESTINAL    CLINIC 

of  one  to  two  days,  of  large  amounts  of  highly  offensive  fer- 
menting ingesta. 

Treatment  of  Syphilitic  Disease  in  the  Stomach  and  In- 
testines.— No  special  therapeutic  measures  are  required  in 
these  cases.  They  are  likely  to  respond  to  any  of  the  usual 
forms  of  antisyphilitic  treatment  energetically  carried  out.  In 
cases  of  chronic  gastritis  in  syphilitic  subjects,  it  will  be  well 
to  try  a  course  of  mercury  by  the  mouth,  or  better,  by  inunc- 
tion, or  possibly  even  hypodermically.  The  ulcers,  infiltra- 
tions, gummata,  etc.,  all  belong  to  the  tertiary  stage  and  are 
best  controlled,  as  a  rule,  by  full  doses  of  the  iodides.  It  is  the 
custom  of  many  syphilographers,  however,  to  employ  mercury 
with  the  iodide  at  this  stage,  and  the  results  in  some  stubborn 
cases  seem  to  be  better  than  when  the  latter  is  used  alone. 

Tertiary  manifestations  of  syphilis  may  be  found  both  in  the 
alimentary  canal  of  patients  suffering  from  acquired,  and  those 
having  hereditary,  syphilis.  The  need  of  bearing  in  mind  the 
possibility  that  gastric  symptoms  may  depend  upon  a  syph- 
ilitic lesion  is  clearly  most  important.  To  ignore  it  is  to  risk 
serious  aggravation  through  erroneous  treatment,  and  even  the 
dangers  of  an  unnecessary  operation. 

The  same  is  true  of  patients  showing  signs  of  ulceration  in 
the  bowels.  In  all  such  cases  exhaustive  search  should  be 
made  for  specific  lesions  elsewhere,  since  the  finding  of  these, 
if  followed  by  a  positive  response  to  the  newer  tests  for 
syphilis,  would  insure  a  rapid  cure  usually  of  what  would  other- 
wise likely  be  very  tedious  cases. 

Ehrlich's  "  606."— While  the  third  edition  of  this  work  has  been  going 
through  the  press  the  medical  profession  has  been  profoundly  stirred 
by  the  reports  of  extraordinary  results  obtained  abroad  by  the  use  of 
Ehrlich's  "  606"  (dioxydiamidoarsenbenzol)  in  the  cure  of  syphilis.  This 
new  remedy  is  an  arsenical  compound  elaborated  by  Professor  Ehrlich 
after  several  years  of  patient  research  and  experimentation  and  is  admin- 
istered in  a  single  large  dose  hypodermically  with  results  which,  accord- 
ing to  the  testimony  of  numerous  eminent  syphilographers,  can  only  be 
characterized  as  marvelous. 


LECTURE  LVIII 

INTESTINAL  ULCERS  GENERALLY— HEM- 
ORRHAGE FROM  THE  STOMACH  AND 
INTESTINES 

Various  Forms  of  Intestinal  Ulceration. — Authors  of  the 
most  elaborate  treatises  upon  diseases  of  the  intestines  treat  of 
the  ulcers  of  these  parts  under  a  dozen  or  more  separate  heads ; 
but  having  devoted  special  lectures  to  tuberculous  ulcers,  syph- 
ilitic lesions  of  the  gastro-intestinal  tract  including  syphilitic 
ulcers,  and  dysenteric  ulcers  under  the  head  of  Dysentery,  I 
think  it  will  be  more  practical  and  less  confusing  to  you  if 
the  other  forms  of  ulceration  of  the  intestines  shall  be  con- 
sidered here  together.  In  this  respect  I  shall  be  more  nearly 
following  the  distinguished  lead  of  Ewald,  in  whose  recently 
published  admirable  work  entitled  "  Die  Krankheiten  des 
Darms  und  des  Bauchfells,"  which  has  not  been  translated  into 
English,  all  the  forms  of  intestinal  ulcers  are  discussed  in  a 
single  lecture.  Hemmeter,  in  considering  the  treatment  of  this 
subject,  after  referring  to  duodenal,  syphilitic,  and  dysenteric 
ulcers,  says  under  the  head  of  Treatment :  "  All  other  ulcera- 
tions I  can  safely  say  will  not  be  diagnosed  except  the  catarrhal 
and  tuberculous  ulcers." 

Besides  the  varieties  of  intestinal  ulcers  already  described, 
and  to  be  described  under  the  head  of  Dysentery,  Tubercular 
Ulcerations,  and  Syphilis  of  the  Stomach  and  Intestines,  some 
mention  should  be  made  of  the  following,  which  are  given  in 
the  order  of  their  relative  frequency  and  importance,  rather 
than  in  accordance  with  the  very  elaborate  classifications  of 
Nothnagel  and  others : 

I.  Ulcers  complicating  acute  infectious  diseases,  such  as  the 
fevers,  exanthems,  etc. 

585 


586  THE    GASTRO-INTESTINAL    CLINIC 

2.  Catarrhal  and  stercoral  ulcers,  that  is,  those  occurring  in 
the  inflammatory  affections  of  the  intestinal  mucosa,  and  from 
the  pressure  of  fecai  masses  in  constipation. 

tQ.  Toxic  ulcers  resulting  from  poisoning  by  alcohol,  uraemia, 
or  any  of  the  active  poisons. 

4.  Embolic  and  thrombotic  ulcers. 

5.  Ulcers  resulting  from  faulty  constitutional  states,  such  as 
gout,  scurvy,  and  leukemia. 

6.  Amyloid  ulcers. 

The  general  features  of  these  forms  of  intestinal  ulceration 
I  shall  here  take  up  for  brief  consideration  in  the  above  order. 

1.  Typhoid  fever,  smallpox,  erysipelas,  diphtheria,  anthrax, 
and  the  acute  septic  conditions  are  chief  among  the  acute  in- 
fectious processes  which  are  often  complicated  by  ulceration 
in  the  intestine.  Dysentery  belongs  in  the  same  category,  but 
this  disease  will  claim  separate  consideration  as  belonging  es- 
pecially to  the  affections  of  the  gastro-intestinal  tract,  and  the 
ulcers  peculiar  to  it  will  be  therein  discussed.  In  some  of  the 
acute  infectious  fevers,  including  especially  typhoid,  intestinal 
ulceration  is  frequent,  and  highly  important,  but  I  quite  agree 
with  Ewald  in  the  opinion  that  this  is  not  the  proper  place 
for  the  detailed  consideration  of  such  ulcers,  since  .they  are 
complications  of  maladies  which  cannot  justly  be  classed 
among  the  diseases  of  the  stomach  and  intestines.  The  sub- 
ject is  fully  discussed  in  the  standard  works  on  the  practice  of 
medicine. 

2.  Catarrhal  ulcers  and  those  resulting  from  fecal  accumu- 
lations are  both  frecjuent  and  important.  Moreover  they  be- 
long especially  to  the  classes  of  diseases  which  we  are  studying 
in  this  series  of  lectures.  They  begin  as  erosions  involving  the 
superficial  layers  of  the  mucosa  only,  and  may  either  directly, 
or  by  coalescing,  extend  over  a  considerable  part  of  the  bowel. 
When  the  catarrhal  process  or  the  fecal  stasis  persists  for  a  long 
time,  the  ulcers  thus  produced  are  liable  to  erode  all  the  layers  of 
the  intestinal  walls,  and  even  produce  perforation.  The  catar- 
rhal ulcers  may  affect  any  part  of  the  bowel,  but  are  most  fre- 


INTESTINAL    ULCERS    GENERALLY  58/ 

quently  encountered  in  the  colon.  Stercoral  ulcerations  affect 
especially  those  parts  where  the  feces  are  most  prone  to  lodge, 
such  as  the  cecum,  the  flexures  of  the  colon,  and  the  rectum. 
Like  the  constipation  upon  which  they  depend,  they  afflict  par- 
ticularly persons  of  a  sedentary  habit. 

Both  these  forms  of  ulceration,  when  they  involve  large  por- 
tions of  the  bowel,  are  liable  in  healing  to  cause  contractions 
with  resulting  obstruction,  and  yet  such  a  mishap  seems  to  be 
uncommon. 

3.  Toxic  ulcers  may  be  caused  by  a  great  variety  of  irri- 
tants, and  the  poison  may  come  from  within  or  without  the 
body.  The  character  and  pathology  of  them  will  vary  some- 
what with  the  cause — the  particular  kind  of  poison  producing 
them.  Alcohol  less  frequently  expends  its  morbid  influence  in 
this  than  in  other  ways  upon  the  tissues  of  the  body;  yet  it  is 
one  of  the  recognized  causes  of  intestinal  ulceration.  The 
graver  cases  of  uraemia  may  be  complicated  by  such  ulcera- 
tions, but  these  in  such  serious  conditions  are  naturally  of  less 
importance  than  the  primary  disease.  Mercury  in  the  massive 
doses  formerly  given,  and  sometimes  still  prescribed  for  syph- 
ilis, can  easily  produce  intestinal  ulceration  of  a  very  aggra- 
vated type.  Numerous  poisons,  especially  arsenic,  antimony, 
etc.,  are  capable  of  exciting  like  lesions,  though  their  toxic  ef- 
fects are  more  commonly  expended  upon  portions  of  the  ali- 
mentary canal  higher  up,  as  in  the  esophagus  and  stomach. 

4.  Embolic  and  thrombotic  ulcerations  possess  some  clinical 
importance,  but  can  scarcely  be  differentiated  from  other  forms 
during  life,  except  in  the  course  of  operations  for  surgical  com- 
plications. They  may  arise  in  consequence  of  endocarditis, 
septic  processes,  or  arteriosclerosis,  and  also  from  any  of  the 
causes  capable  of  producing  thrombosis.  The  emboli  lead  to 
obstruction  of  vessels — most  frequently  the  smaller  ones — in 
the  mucosa,  and  the  resulting  hemorrhagic  infarcts  undergo 
necrosis  with  the  formation  of  ulcers.  These,  according  to 
Boas,  occur  oftenest  between  the  duodenum  and  the  cecum. 
The  ulcers  vary  greatly  in  size ;  this  depending  upon  the  ex- 


588  THE    GASTRO-IXTESTIXAL    CLINIC 

tent  of  the  hemorrhage.  The  ulceration  may  be  deep  and  lead 
to  perforation  of  the  peritoneal  cavity.  In  septic  embolism 
from  ulcerative  endocarditis,  Boas  points  out  especially  that 
tliere  may  be  very  small  embolic  abscesses  between  the  submu- 
cosa  and  mucosa,  which  open  within  the  lumen  of  the  bowel 
with  the  production  of  numerous  ulcers. 

5.  Gouty  ulcers  are  so  rare  that  many  authors  deny  that 
they  ever  occur,  while  though  scorbutic  ulceration  involving 
Peyer's  patches  is  a  frequent  complication  of  scurvy,  this  dis- 
ease itself  is  becoming  very  uncommon,  except  in  hand-fed  in- 
fants. Intestinal  ulceration  has  been  exceptionally  observed 
in  leukemia  as  a  consequence  of  infiltration  of  the  lymphatic 
structures  in  the  bowels  and  secondary  necrosis  of  the  same. 

6.  Amyloid  ulcers  of  the  intestines  may  possibly  complicate 
amyloid  disease  of  the  liver  and  kidneys  or  other  organs,  but 
are  exceedingly  seldom  encountered ;  probably  never  diag- 
nosed. They  may  be  of  any  size,  and  sometimes  involve  large 
portions  of  the  gut,  but  do  not  cicatrize,  so  that  obstructive  con- 
traction never  results. 

Symptoms  of  Intestinal  Ulceration. — These  are  very  sim- 
ilar for  all  the  varieties  of  ulcers  occurring  in  this  region.  As 
a  rule,  you  will  not  be  able  to  distinguish  between  them  by  any 
symptoms  or  physical  signs,  though  the  character  of  the  ac- 
companying disease,  as  in  the  case  of  tuberculosis  or  syphilis, 
may  sometimes  enable  you  to  make  the  diagnosis.  We  can 
only  study  the  symptomatology  of  intestinal  ulceration  as  a 
whole.  There  are  many  cases  which  present  no  symptoms, 
and  even  some  very  mild  ones  in  which  the  usual  symptoms  or 
sign  of  tenderness  on  pressure  over  the  corresponding  part  of 
the  abdomen  cannot  be  obtained.  Then  again,  the  catarrhal 
inflammation  which  always  accompanies  ulcers  of  the  intestine 
greatly  obscures  the  clinical  picture.  Xevertheless  a  patient 
watching  of  the  stools,  and  study  of  them  microscopically  as 
well  as  chemically,  would  rarely  fail  in  such  cases  to  reveal 
from  time  to  time  indubitable  indications  of  the  ulcerative 
process. 


INTESTINAL    ULCERS    GENERALLY  589 

Pain  of  the  spontaneous  kind,  though  present  at  times  in  these 
cases,  is  quite  frequently  absent  even  when  the  ulcers  are  nu- 
merous and  large,  especially  when  there  is  neither  severe  diar- 
rhea nor  marked  constipation.  Pain  on  pressure  or  palpa- 
tion is  very  much  more  frequently  present  and  to  be  discovered 
by  a  careful  search  for  it.  Very  deep  pressure  while  the  pa- 
tient relaxes  his  abdominal  muscles  by  flexing  the  knees,  and 
keeps  up  slow,  sighing  respiration,  will  often  reveal  tenderness 
otherwise  not  to  be  elicited.  Tenderness  ascertained  in  this 
way  would  assist  in  confirming  the  diagnosis  of  ulceration  in 
the  part  directly  beneath  the  tender  spot,  though  over  the 
cecum  it  might  mean  a  catarrhal  appendix,  and  over  anv  por- 
tion of  the  abdomen  it  might  signify  simply  a  catarrhal  in- 
flammation. But  the  tenderness  over  an  ulcer  is  generally 
more  acute. 

Then,  in  neurasthenic  patients  you  may  often  find  tender 
spots  over  the  sympathetic  nerve  plexuses  of  the  abdomen,  but 
a  peculiarity  of  this  latter  tenderness  is  that  by  persistent  and 
not  too  severe  pressure  in  such  places  it  gradually  diminishes, 
often  disappearing  entirely,  while  the  pain  caused  by  pressure 
over  an  ulcer  will  usually  persist  and  even  increase  as  you 
press  longer. 

Constipation  and  Diarrhea. — One  or  the  other  of  these  is 
nearly  always  present  in  marked  cases,  and  it  is  the  rule,  to 
which,  however,  there  are  many  exceptions,  that  in  cases  in 
which  there  are  many  ulcers,  especially  in  the  lower  bowel, 
diarrhea  will  be  a  rather  persistent  and  troublesome  symptom. 
But  sometimes  even  under  these  circumstances  constipation 
will  exist ;  and  exceptionally  you  may  be  misled  by  the  bowels' 
continuing  to  act  normally. 

Blood,  pus,  and  necrotic  tissue  are  to  some  extent  character- 
istic, but  all  of  them  may  come  from  abscesses,  and  pus,  if 
present  in  large  amount,  would  point  decidedly  to  the  latter. 
Mucus  alone  might  well  signify  nothing  more  than  catarrh. 
Blood  may  arise  from  various  congestive  conditions,  but  in 
large  quantity  nearly  always  signifies  the  erosion  of  a  vessel 


590  THE    GASTRO-IXTESTIXAL    CLINIC 

by  ulceration  in  some  part  of  the  gastro-intestinal  tract.  AMien 
it  is  fresh,  and  of  a  bright  red  color,  it  has  generally  come  from 
some  place  in  the  rectum  or  colon,  though  when  the  peristalsis 
is  vuiusually  active,  as  in  diarrhea,  you  should  not  forget  that 
blood  originating  in  the  small  intestine,  and,  very  exception- 
ally, even  in  the  stomach  or  esophagus,  may  pass  the  anus 
without  having  undergone  any  marked  change.  Usually  the 
more  altered  the  blood  is,  and  the  more  intimately  intermingled 
blood  or  pus  or  necrotic  tissue  is  with  the  feces,  the  higher 
up  in  the  tract  it  has  originated. 

Tubercle  bacilli  in  the  feces  are  not  necessarily  significant  of 
tubercular  ulceration,  unless  found  at  a  time  when  the  patient 
is  not  having  any  sputa  or  are  present  constantly  in  large  num- 
bers;  and  on  the  other  hand,  the  failure  to  find  the  bacilli  at 
a  single  examination  would  not  prove  that  tuberculosis  was 
not  present,  and  that  the  ulcers  were  catarrhal  or  of  any  non- 
tubercular  origin. 

Fever  indicates  nothing  in  regard  to  intestinal  ulceration, 
since  it  can  proceed  from  so  many  other  causes. 

The  general  condition  of  the  patient  may  or  may  not  be  so 
much  affected  by  intestinal  ulceration  as  to  awaken  a  suspicion 
of  its  existence.  As  a  rule  in  those  ulcers,  for  example,  which 
are  likel}^  to  develop  in  chronic  intestinal  catarrh,  you  will  nearly 
always  find  a  marked  lowering  of  the  general  health,  but  this 
verv  often  results  from  the  catarrhal  inflammation  alone,  be- 
fore the  ulceration  has  developed.  Very  exceptionally  the 
flesh,  strength,  and  color  may  remain  about  as  in  health,  in 
spite  of  both  the  catarrh  and  ulceration.  In  the  other  form  of 
intestinal  ulcers  also,  the  general  state  would  depend  chiefly 
upon  the  primary  disease  and  the  extent  to  which  it  had  re- 
duced the  patient. 

Diagnosis. — As  previously  intimated,  it  will  often  be  ex- 
tremely difficult,  or  even  impossible,  to  differentiate  between  the 
different  varieties  of  intestinal  ulcers  except  when  it  is  prac- 
ticable by  the  symptoms  of  the  primary  disease,  or  the  clinical 
picture  as  a  whole,  to  make  the  diagnosis.     Even  to  determine 


IXTESTIXAL    ULCERS    GEXEIL\LLY  591 

positively,  in  certain  of  the  less  pronounced  cases,  that  ulcers 
of  the  intestines  exist  is  by  no  means  easy.  AMien  blood  passes 
the  anus  in  either  small  or  large  amounts,  and  at  the  same 
time,  small,  or  very  moderate  amotmts  of  pus  and  necrotic 
tissue  are  found  frequently  in  the  stools  without  the  existence 
of  fever  and  the  other  signs  of  abscess,  you  may  well  suspect 
the  presence  of  ulceration^  especially  if  you  can  also  find  cir- 
cumscribed spots  over  portions  of  the  intestines  which  are 
painful  on  pressure.  Then  the  coexistence  of  a  disease,  such 
as  dysentery,  typhoid  fever,  or  a  long-standing  enteritis  or 
colitis,  would  greatly  increase  the  probability  of  ulcer,  and,  in 
fact,  in  most  cases  suffice  to  determine  the  diagnosis  posi- 
tively. 

Treatment. — As  in  the  case  of  the  diagnosis,  so  the  treat- 
ment of  ulcers  of  the  bowels  must  depend  in  large  measure  upon 
the  character  and  requirements  of  the  primary  disease.  In  the 
ulceration,  for  example,  which  so  often  occurs  as  a  complication 
of  typhoid  fever,  you  will  insist  upon  the  most  absolute  rest 
for  the  patient,  the  blandest  possible  diet,  and  then  prevent 
peristalsis  by  a  bold  emplopnent  of  opium  and  astringents 
with  the  help  of  ice-bags  locally,  knowing  that  it  is  a  tempo- 
rary matter,  and  that  with  the  subsidence  of  the  fever,  the 
hemorrhage,  as  well  as  the  ulceration  which  causes  it,  will 
speedily  cease.  In  the  ulcers  from  embolism  or  thrombosis, 
you  will  devote  yourself  to  the  task  of  curing  the  endocarditis, 
septicaemia  or  other  disease  upon  which  it  depends,  with  the  ad- 
dition of  any  needed  local  measures  to  control  hemorrhage  or 
pain. 

In  the  catarrhal  or  follicular  forjii  of  ulcers  the  problem  will 
be  somewhat  different,  and  here  you  will  need  to  rely  largely 
upon  the  local  measures  of  treatment  in  addition  to  the  general 
mode  of  therapeusis.  dietetic  and  otherwise,  which  is  required 
for  the  intestinal  catarrh.  Full  directions  on  this  head  will  be 
found  in  Lecture  LX\'I.  devoted  to  that  subject:  and  indeed, 
the  methods  of  applying  antiseptics  and  astringents  by  the 
rectum  for  the  cure  of  intestinal  catarrh,  will  prove,  in  the 


592  THE    GASTRO-INTESTINAL    CLINIC 

main,  the  most  efficient  for  the  ulceration.  Ewald  refers  to 
the  difficulties  usually  encountered  here  on  account  of  the  ex- 
treme irritability  which  the  intestinal  mucosa  often  manifests, 
antl  recommends  suppositories  of  cocaine  to  overcome  it.  I 
have  found  3-grain  or  5-grain  suppositories  of  ichthyol,  in- 
serted in  the  rectum  once  or  twice  a  day,  to  answer  this  pur- 
pose admirably,  and  at  the  same  time  to  aid  much  in  disin- 
fecting and  healing  the  lesions.  The  infusion  of  slippery  elm 
recommended  by  Turck  of  Chicago,  as  a  menstruum  for  medi- 
caments in  chronic  catarrh  of  the  colon,  is  still  more  helpful  by 
its  demulcent  influence  in  these  cases.  A  large  and  free  use 
should  be  made  of  bismuth,  and  every  effort  be  made  to  have 
an  emulsion  of  it  with  slippery-elm  infusion  introduced  high 
enough  up  into  the  bowel  to  reach  any  ulcers  that  may  be  in 
the  cecum  or  ascending  colon,  which  can  be  accomplished 
usually  by  position,  as  advised  by  Turck,  or  in  some  cases, 
better  by  the  use  of  a  long  and  semi-flexible  rubber  tube. 

Ewald  strongly  advises  the  injection  of  a  0.2  per  cent,  to 
0.3  per  cent,  solution  of  nitrate  of  silver,  and  I  have  seen  ex- 
cellent results  from  the  introduction  every  other  night  of  a 
solution  of  carbolic  acid  and  Listerine,  according  to  the  for- 
mula given  in  Lecture  LXVI.  on  Chronic  Catarrh  of  the  In- 
testines. 

In  all  these  cases,  whether  the  prevailing  condition  of  the 
bowels  seemed  to  be  one  of  constipation  or  diarrhea,  I  have 
noticed  favorable  effects,  as  a  rule,  from  the  administration 
every  day  or  two  of  a  small  dose  of  castor  oil,  or  some  other 
equally  gently  acting  and  effective  laxative.  Even  when  there 
are  loose  stools  passing  daily,  there  are  often  hard  fecal 
masses  lodged  in  the  flexures  or  other  stagnant  pouches  of  the 
colon,  and  not  until  these  are  removed  and  prevented  from  re- 
accumulating,  will  the  catarrhal,  and  still  less  the  ulcerative, 
process  take  on  a  healthy  reparative  action. 

I  have  at  times  administered  the  more  highly  refined  prepa- 
rations of  petroleum  such  as  vaselin,  albolene,  etc.,  pleasantly 
flavored,  and  been  pleased  with  their  results  upon  the  bowels 


INTESTINAL    ULCERS    GENERALLY  593 

in  such  cases  ^s  are  now  under  consideration,  and  more  fre- 
quently still  in  cases  of  simple  constipation  from  chronic  in- 
testinal catarrh.  One  or  two  teaspoonfuls  of  vaselin  at  bed- 
time would  often  overcome  the  constipation  in  the  most  gentle 
and  satisfactory  way,  and  at  the  same  time  exercise  apparently 
a  soothing  and  healing  effect  upon  the  lesion  in  the  mucosa. 
But  in  persons  with  any  cardiac  weakness,  I  soon  noticed  that 
the  circulation  was  depressed  by  the  remedy,  and  as  many  of 
the  patients  afflicted  with  these  troubles  have  at  the  same  time 
weak  hearts,  I  was  obliged  to  abandon  the  use  of  it.  Quite  re- 
cently I  have  been  prescribing  a  still  more  highly  refined 
preparation  of  the  kind  called  Purpetrol,  said  to  be  made  from 
a  Russian  petroleum,  and  find  it  effective  in  doses  of  about  1-2 
an  ounce,  given  once  or  twice  a  day  on  an  empty  stomach.  So 
far,  I  have  not  noticed  any  marked  cardiac  depression  from  its 
use,  though  should  be  watchful  as  to  this  in  the  case  of  any 
patients  having  a  particularly  weak  heart.  Its  influence  is 
very  bland  and  soothing  and  the  stool  results  without  griping, 
as  a  rule,  but  it  is  truth  to  say  that  it  is  in  no  sense  an  active 
purgative,  and  in  persons  who  are  at  all  obstinately  consti- 
pated, needs  to  be  supplemented  by  some  more  decided  aperi- 
ent. The  valuable  feature  of  such  a  mineral  oil  is,  that  it  is 
absolutely  non-irritating  to  the  whole  digestive  tract,  which  is 
a  great  desideratum. 

Olive  oil  or  cotton-seed  oil,  which  in  doses  of  o'l  to  ovi,  in- 
troduced at  bedtime  by  enema  and  retained  till  morning,  is  so 
highly  effective  in  overcoming  the  constipation  of  chronic  in- 
testinal catarrh  and  muco-membranous  colitis,  may  fail,  or 
prove  wholly  unsuitable  in  cases  of  intestinal  ulcers,  especially 
when  these  are  in  the  colon,  because  of  its  slightly  disturbing 
effect.  Even  when  combined  with  full  doses  of  bismuth,  as  I 
have  been  accustomed  to  direct  in  certain  cases  of  the  former 
ailments,  it  is  by  no  means  sure  not  to  disagree  in  the  presence 
of  complicating  ulcers  affecting  the  lower  colon. 

Since  the  treatment  of  syphilitic,  dysenteric,  and  tuberculous 
ulcers  of  the  intestines  is  sufficiently  discussed  in  the  lectures 


594  THE    GASTRO-INTESTINAL    CLINIC 

devoted  to  those  subjects,  I  need  not  take  up  here  the  treat- 
ment of  those  special  forms  of  ulceration. 


HEMORRHAGE    FROM    THE    STOMACH    AND     INTESTINES 

In  various  lectures  of  this  series  I  have  considered  the  more 
frequent  causes  of  hemorrhage  from  the  gastro-intestinal  tract, 
such  as  round  ulcer  of  the  stomach  or  duodenum,  cancer, 
syphilitic,  tubercular,  dysenteric,  and  simple  catarrhal  ulcer- 
ation of  the  tract,  and  also  the  rare  possibility  of  hemorrhage 
from  benign  polypoid  growths  in  either  the  stomach  or  in- 
testines. 

In  Lecture  XV.  under  the  title  of  A  Symptomatic  Guide  to 
Diagnosis,  practically  all  the  known  conditions  which  are 
capable  of  causing  blood  to  appear  in  either  the  vomit  or  the 
stools  are  catalogued,  so  that  those  not  fully  considered  else- 
where in  this  book  can  easily  be  looked  up  in  other  works  in 
which  the  causative  diseases  or  disorders  are  discussed. 

But,  besides  the  gastro-intestinal  causes  of  hemorrhage, 
there  are  some  others  of  sufficient  importance  and  frequency  to 
merit  special  mention  here.  Then  there  are  the  cases  in 
which  the  hemorrhage  is  from  the  respiratory  tract,  mouth, 
pharynx  or  gullet,  the  blood  appearing  either  in  the  vomit  or 
stools,  and  a  hurried  resume  of  all  the  possible  causes  of  the 
appearance  of  blood  in  either  the  vomit  or  stools  may  be  of 
assistance  to  you. 

For  our  purposes  the  appearance  of  blood  in  either  may  be 
divided  into  the  following  five  classes: 

1.  Small  quantity  of  either  fresh  or  changed  blood  vomited 
with  usually  no  signs  of  blood  in  the  stools. 

2.  Moderate  or  large  quantity  of  blood  vomited  and  usually 
altered  blood  resembling  coffee-grounds,  with  possibly  some 
clotted  fresh  blood  in  the  stools. 

3.  Small  amount  of  bright  or  dark-red  blood  in  the  stools, 
but  none  in  the  vomit. 

4.  Altered  blood  in  the  stools  with  usually  none  in  the  vomit. 


HEMORRHAGE    FROM    THE   STOMACH    AND   INTESTINES    595 

5.  Large  or  small  amounts  of  blood  in  the  stools,  some  of  it 
often  of  dark  red  color,  and  some  of  it  brownish  and  altered, 
with  usually  blood  or  altered  blood  also  in  the  vomit. 

We  may  add :  Minute  invisible  quantities  of  blood  (occult 
blood)  in  both  stomach  contents  and  feces  detected  by  chem- 
ical tests  only.      (See  page  599.) 

The  Significance  of  Blood  in  Vomit  or  Stools. —  i.  The 
vomiting  of  small  amounts  of  blood  is  more  likely  to  signify 
cancer  than  ulcer  or  any  other  disease,  but  may  result  from  an 
ulcer  in  the  mouth,  pharynx  or  nasopharynx,  esophagus,  stom- 
ach, or  even  the  duodenum.  It  may  proceed  from  the  gums, 
the  socket  of  a  recently  extracted  tooth,  or  from  any  other  tri- 
fling injury  in  the  mouth  or  the  mucous  tracts  opening  into  it. 
What  has  been  called  vicarious  menstruation,  but  is  probably 
really  a  leakage  from  a  congested  gastric  mucosa  aggravated, 
as  all  digestive  troubles  are  prone  to  be  at  the  menstrual 
period,  may  be  responsible  for  the  presence  of  either  small  or 
large  Cjuantities  of  blood  in  the  vomit.  So,  also,  may  erosions 
of  the  stomach,  and  hepatic  cirrhosis,  heart  disease  with  fail- 
ing compensation,  or  any  other  cause  of  passive  congestion  in 
the  portal  vessels.  The  unskillful  use  of  the  stomach  tube  may 
possibly  provoke  small  bleedings  from  a  hypersemic  gastric 
mucosa,  and  in  such  cases  I  have  sometimes  seen  a  few  drops 
tinge  the  wash  water  during  the  lavage,  even  when  the  tube 
was  introduced  with  the  utmost  possible  gentleness  and  the 
patient  had  not  struggled  or  had  spasmodic  contractions  of  the 
gastric  musculature  to  produce  an  injury  of  the  membrane. 

As  a  rule,  in  the  smaller  hemorrhages  from  the  stomach,  the 
vomited  blood  is  changed  in  character  by  digestion  and  is  of  a 
dark  brownish  color  resembling-  coffee-grounds.  It  is  rare  for 
small  amounts  of  blood  to  be  vomited  in  the  fresh  state,  unless 
when  the  stomach  is  exceedingly  irritable,  so  that  emesis  is 
occurring  almost  constantly.  Then  much,  too,  depends  upon 
the  activity  of  the  peptic  digestion.  When  a  normal  proportion 
of  pepsin  and  HCl  is  secreted,  a  small  amount  of  blood  leaking 
out  into  the  viscus  is  very  rapidly  changed  by  digestion  so  that, 


59^  THE    GASTRO-INTESTINAL    CLINIC 

in  even  half  an  hour,  it  would  no  longer  appear  as  blood, 
whereas,  with  a  very  deficient  secretion  of  HCl  and  the  fer- 
ments, the  blood  is  changed  more  slowly,  and  after  a  copious 
hemorrhage,  even  with  a  very  active  digestion,  vomiting  is 
commonly  provoked  more  speedily  and  much  of  the  blood  may 
then  come  up  in  an  unchanged  form. 

Blood  may  be  vomited,  or  at  least  tinge  the  vomitus,  in  any 
of  the  severer  forms  of  ansemia,  or  in  purpura,  scurvy,  or  in 
other  constitutional  affections  which  greatly  alter  its  crasis. 

The  Source  of  the  Larger  Gastric  Hemorrhages. — 2.  -A 
relatively  large  hemorrhage  is  more  likely  to  have  come  from 
a  peptic  ulcer  in  the  lower  end  of  the  esophagus,  from  the 
stomach  itself  (most  frequently)  or  from  the  duodenum,  than 
from  cancer  or  any  other  cause,  though  you  should  not  forget 
that  in  either  cancer  or  ulcer,  either  large  or  small  amounts  of 
blood  may  be  vomited,  and  that  such  blood  may  be  bright 
and  red  or  dark  and  partly  digested,  whatever  the  cause  of  the 
hemorrhage  may  have  been. 

A  moderately  large  hemorrhage,  or  small  hemorrhages  from 
the  stomach  may  result  from  any  of  the  conditions  mentioned 
above  as  causes,  except  that  in  the  cases  of  slight  injuries  in  the 
mouth  or  its  vicinity,  or  irritation  of  the  gastric  mucosa  from 
the  use  of  the  tube,  there  is  very  rarely  any  considerable  loss 
of  blood  unless  the  tube  should  perforate  an  ulcer. 

The  most  profuse  and  dangerous  hemorrhages  from  the 
stomach  arise  from  the  eroding  of  a  blood-vessel  of  consider- 
able size  by  the  extension  of  a  peptic  ulcer,  or  less  frequently 
from  the  ulceration  of  a  cancer.  A  large  amount  of  blood, 
often  of  a  bright  red  color,  may  be  vomited  when  its  source 
has  been  the  rupture  of  a  vessel  in  a  tubercular  cavity  of  the 
lungs.  It  is  possible,  too,  though  less  common,  to  have  a  small 
quantity  of  Ijlood  swallowed  and  afterward  vomited  in  altered 
form,  during,  or  subsequent  to,  a  pulmonary  hemorrhage.  In 
such  a  ca.se  the  blood  would  almost  certainly  be  digested  and 
changed  to  a  dark  brown  color,  except  when  the  gastric  juice 
was  very  deficient. 


•       HEMORRHAGE    FROM    THE    STOMACH    AND    INTESTINES       597 

Less  Frequent  Causes  of  Hematemesis. — Other  much  less 
frequent  causes  of  hematemesis,  which  is  then  usually  rather 
copious,  are  aneurisms  of  the  esophageal  or  gastric  arteries  or 
varices  of  the  veins  in  the  same  parts,  and  erosions  of  the  ves- 
sels in  the  same  by  the  action  of  strong  acids  or  other  irritant 
poisons  or  foreign  bodies  swallowed.  Very  hot  ingesta  are  also 
said  to  have  caused  the  vomiting  of  blood,  and  the  amount  lost 
would  be  large  in  case  a  vessel  should  be  thus  eroded. 

Moderate  hemorrhages  occasionally  result  also  from  the  con- 
gestion of  the  gastric  mucosa,  or  are  due  to  changes  in 
the  blood  itself,  incident  to  the  course  of  severe  cases  of  the 
acute  infectious  diseases,  especially  yellow  fever,  acute  yellow 
atrophy  of  the  liver,  cholera,  and  in  the  severer  forms  of  ma- 
larial fevers ;  also  in  typhoid  fever,  relapsing  fever,  smallpox, 
typhus  fever,  scarlatina,  and  exceptionally  even  in  measles. 

Other  causes  of  considerable  gastric  hemorrhages  mentioned 
by  authors  are  melena  neonatorum,  nephritis,  and  so-called 
idiopathic  gastric  hemorrhage,  but  in  all  these  cases  the  cause, 
it  seems  to  me,  can  be  traced  to  one  of  the  conditions  already 
described  above.  The  exceedingly  rare  instances  of  blood 
vomited  in  nephritis  have  been  shown  to  be  dependent  upon 
miliary  aneurisms  in  the  gastric  mucus  membra*ne  due,  as  all 
aneurisms  are,  to  an  atheromatous  condition  of  the  vessels. 
The  loss  of  blood  in  the  new-born  through  the  stomach  and  in- 
testines is  of  unknown  origin,  but  apparently  the  cause  is  a 
depraved  state  of  the  blood  itself. 

The  Source  of  Blood  Found  in  the  Stools. — 3.  Fresh  blood 
in  the  stools,  with  none  in  the  vomit,  comes  most  commonly 
from  hemorrhoids  or  ulcers  in  the  rectum  or  lower  colon ;  but 
a  cancer  or  even  polypi,  in  the  same  region,  may  also  give  rise 
to  such  bleedings. 

4.  Altered  blood  in  the  stools,  with  usually  none  in  the  vomit, 
points  to  ulcer,  cancer,  or  rarely  to  polypi  or  other  innocent 
form  of  tumor  rather  high  up  in  the  bowel — in  the  cecum,  as- 
cending colon,  hepatic  flexure,  or  ileum  most  frequently. 

It  may  also  be  due  to  any  of  the  forms  of  intestinal  ulcera- 


598  THE    GASTRO-INTESTINAL    CLINIC 

tion  already  described  in  this  and  the  preceding  lectures,  or  to 
such  acute  infectious  diseases  as  typhoid  fever,  etc. 

'Blood  in  Both  Vomit  and  Stools. — 5.  There  has  generally 
been  a  copious  hemorrhage  in  either  the  stomach  or  duo- 
denum— except  in  the  case  of  hemoptysis  with  a  large  portion 
of  the  blood  swallowed — when  you  find  blood  both  in  the  vomit 
and  stools  in  considerable  quantities,  whether  all  of  that  in  the 
stools  be  dark  and  altered,  or  a  part  of  it  is  still  recognizable 
as  blood.  The  most  frequent  cause  of  such  a  large  hemor- 
rhage is  an  eroded  vessel  as  a  result  of  either  ulcer  or  cancer — 
more  frequently  the  former — in  the  stomach  or  duodenum. 

Symptoms. — Small  bleedings  may  occur  in  the  stomach  or 
bowels  without  symptoms  other  than  the  appearance  of  blood, 
either  fresh  or  altered  by  digestion,  in  the  vomit  or  stools  as 
above  described.  But  a  large  hem.orrhage,  besides  nearly  al- 
ways revealing  itself  by  hematemesis  as  well  as  by  bloody 
stools,  will  necessarily  produce  a  feeling  of  weakness,  faint- 
ness,  or  even  collapse  with  unconsciousness,  and  sometimes 
convulsions. 

The  face  and  mucous  membranes  will  also  become  pale,  and 
fever  generally  develops  after  a  copious  hemorrhage.  AMien 
the  blood  comes  from  an  artery  and  is  vomited  very  soon,  it 
may  be  bright ;  but  when  from  a  vein  it  will  be  darker,  and  in 
either  case,  if  long  retained  in  the  stomach,  or  even  if  re- 
tained a  comparatively  short  time  when  there  is  an  abundance 
of  HCl  and  pepsin,  it  may  be  completely  changed  by  digestion 
and  present  the  brownish  appearance  of  coffee-grounds.  In 
very  serious  forms  of  hematemesis,  blindness  or  other  dis- 
turbances of  vision  have  exceptionally  been  noted. 

Diagnosis. — You  will  not  usually  have  much  difficulty  in 
recognizing  fresh  blood  by  its  naked-eye  appearance,  especially 
if  present  in  much  quantity.  When  the  amount  is  very  small, 
you  can  sometimes  identify  it  by  recognizing  the  blood 
corpuscles  under  the  microscope.  Or  the  modified  Weber  test 
may  be  employed. 

The  method  is  thus  carried  out : 


HEMORRHAGE    FROM    THE   STOMACH    AND   INTESTINES    599 

Tests  for  Occult  Blood.— The  ModiHed  Weber  Test;  5  to 
10  CO.  of  the  filtered  stomach  contents  are  thoroughly  mixed 
in  a  test  tube  with  one-third  of  their  volume  of  glacial  acetic 
acid.  To  this  mixture  add  one-third  to  one-half  volume  of 
ether.  ]\Iix  very  thoroughly,  without  shaking  hard,  for  four 
or  five  minutes,  and  then  allow  the  mixture  to  stand  a  few 
minutes.  Decant  or  remove  the  clear  ethereal  extract  which 
separates  at  the  top  of  the  mixture,  and  test  this  by  adding 
10  to  20  drops  of  a  freshly  prepared  alcoholic  solution  of 
guaiac,  and  20  to  30  drops  of  old  well-oxidized  turpentine  (or 
better,  a  like  amount  of  hydrogen  peroxide  solution).  The 
mixture  will  promptly  turn  a  violet  blue  when  blood  is  present. 
Greenish  or  reddish-brown  changes  must  not  be  considered  posi- 
tive. The  patient  should  not  have  eaten  meat  or  meat  products 
shortly  before  this  test.  The  aloin  test  is  made  in  the  same 
manner  as  the  above,  except  that  a  fresh  alcoholic  solution  of 
aloin  is  substituted  for  the  guaiac  tincture,  and  here  the  tur- 
pentine has  been  found  more  delicate  than  the  peroxide.  A 
positive  reaction  consists  in  the  production  of  a  cherry-red 
color  in  the  final  mixture.  The  two  tests  are  about  equally 
delicate,  the  aloin  test  being  perhaps  slightly  the  more  so. 

The  henzidin  test,  originally  proposed  by  O.  and  R.  Adler, 
was  too  delicate  for  practical  work;  but,  as  modified  by  Schles- 
inger  and  Hoist,  this  objection  is  removed.  F.  W.  White 
[Boston  Med.  and  Surg.  Jour.,  June  10,  1909)  has  made  a 
thorough  comparative  study  of  the  benzidin  and  guaiac  tests, 
and  concludes  that  with  proper  reagents,  cleanliness,  and  care, 
the  benzidin  test  is  reliable  and  not  too  delicate,  being  slightly 
more  so  than  the  guaiac  test.  He  recommends  the  following 
technic:  I.  A  few  c.c.  of  gastric  contents  (filter  if  food  pres- 
ent), or  a  pea-sized  piece  of  feces  mixed  with  4  c.c.  of  water, 
are  boiled  in  a  lightly  stoppered  test  tube  for  not  more  than 
one-half  minute.  H.  A  knife-point  of  benzidin  is  shaken  into 
2  c.c.  glacial  acetic  acid ;  an  ordinary  conical  minim  glass  is 
filled  to  the  lo-minim  mark  with  this  solution,  and  commercial 
dioxygen  (Oakland)  is  added  up  to  the  one-drachm  mark,  and 


600  THE    GASTRO-IXTESTIXAL    CLIXIC 

the  mixture  stirred  with  a  glass  rod  and  ahowed  to  stand  a  few 
minutes  (to  test  the  cleanness  of  the  conical  glass,  etc.).  III. 
Three  drops  of  the  boiled  stomach  contents  or  feces  are  added, 
with  or  without  stirring.  A  clear  green  or  blue  color  appears 
in  one  to  two  minutes  when  blood  is  present.  Essential  to  the 
success  of  the  test  are  the  following:  Absolute  cleanness  of 
glassware,  etc. ;  exclusion  from  the  diet  of  meat  and  fish  and 
their  juices  and  broths  (for  three  or  four  days  when  feces  are 
to  be  tested);  exclusion  of  iron  salts,  KI,  CuSOi,  and  other 
metal  salts,  charcoal  and  formaldehyde.  The  stool  must  be 
reasonably  fresh — less  than  24  hours  old.  Failure  sometimes 
results  from  untrustworthy  reagents.  AMiite  has  had  uni- 
form satisfaction  in  the  use  of  ^Merck's  "  highest  purity  "  ben- 
zidin  or  "  benzidin  for  blood  test,"  and  Oakland  dioxygen. 

For  very  small  amounts  of  blood,  especially  where  a  few 
streaks  are  present,  not  mixed  through  the  specimen,  the  hemin 
crystal  test  may  be  safest. 

.  Test  for  Hemin  Crystals. — The  old  Teichmann  test  may  be 
made  by  adding  two  or  three  crystals  of  XaCl  to  a  bit  of  the 
dried  specimen  to  be  tested,  on  a  slide,  covering  with  a  cover- 
glass,  running  a  drop  or  two  of  glacial  acetic  acid  under  the 
cover-glass,  heating  almost  to  the  boiling-point  for  a  minute 
or  two,  and  examining  for  the  characteristic  dark-brown  or 
black  rhombic  crystals  of  hemin.  The  test  as  modified  by 
Stryzsisowski  is  probably  somewhat  more  delicate  and  satis- 
factory. His  reagent  is  made  by  mixing  i  c.c.  each  of  glacial 
acetic  acid,  alcohol,  and  distilled  water,  and  adding  three  to 
five  drops  of  hydriodic  acid  of  a  specific  gravity  of  1.5.  The 
specimen  is  dried  on  a  slide,  a  cover-glass  applied,  two  or  three 
drops  of  the  reagent  added,  and  the  process  completed  as  with 
the  Teichmann  test. 

The  Iron  Test  for  Blood. — Place  in  a  small  porcelain  dish 
a  little  of  the  blackish  sediment  from  the  stomach  contents  or 
feces.  To  this  add  a  small  amount — a  few  crystals  will  an- 
swer— of  chlorate  of  potassium,  as  well  as  one  or  two  drops 
of  concentrated  HCl,  and  heat  slowlv  over  a  flame.    If  neces- 


HEMORRHAGE    FROM    THE   STOMACH    AND    INTESTINES   6oi 

sary  add  enough  more  HCl  to  make  the  dark  color  of  the  sedi- 
ment entirely  disappear.  When  all  the  chlorate  has  dissolved, 
add  a  few  drops — i  to  2 — of  a  5  per  cent,  solution  of  po- 
tassium ferrocyanide.  If  iron  be  present,  the  pronounced  blue 
color  of  Prussian  blue  will  develop.  This  is  a  very  trust- 
worthy test  provided  the  patient  has  not  been  taking  iron  as  a 
medicine,  nor  recently  eaten  raw  or  rare  meat,  which  could 
give  the  same  reaction. 

Blood  from  the  stomach  and  that  from  the  lungs  or  upper 
air  passages. — In  Lecture  LIII.  I  have  given  the  chief  diagnos- 
tic differences  between  blood  proceeding  from  the  lungs  or 
other  parts  above  the  stomach  and  from  that  viscus  itself. 
When  a  tubercular  involvement  of  the  lungs  has  been  diag- 
nosed, and  there  is,  at  the  same  time,  a  gastric  ulcer  or  a 
congested  condition  of  the  gastric  mucosa,  vomited  blood  might 
possibly  have  come  from  either,  though  usually  the  fact  of  a 
preceding  hemoptysis  would  be  known,  and  then  the  probability 
would  be  that  the  blood  originated  in  the  lung.  The  finding  of 
tubercular  bacilli  in  the  ejecta  would  be  decisive,  as  a  rule. 

Treatment. — In  Lectures  LIV.  and  LXII.  in  connection  with 
the  treatment  of  ulcer  and  cancer  of  the  stomach,  I  have  con- 
sidered the  principal  remedies  for  gastric  hemorrhage,  what- 
ever its  immediate  cause. 

These  include  absolute  rest,  withdrawal  of  all  food  and  drink 
by  mouth,  except  possibly  cracked  ice,  morphine  hypoder- 
mically,  an  ice  bag  to  the  abdomen,  gelatin  by  mouth  or  sub- 
cutaneously,  calcium  chloride,  adrenalin,  ergot.  Bismuth  and 
astringents,  e.g.  gallic  acid,  are  sometimes  used,  especially  for 
intestinal  hemorrhage.  If  the  pulse  is  full  and  tense,  aconite 
may  be  given.  Salt  solution  by  rectum  or  sub-cutaneously 
must  be  given  when  collapse  threatens. 


LECTURE  LIX 

CARCINOMA   AND    OTHER   TUMORS   OF 
THE    STOMACH 

In  considering  the  subject  of  cancer  of  the  stomach,  I 
shall  limit  myself  to  its  more  practical  aspects,  summing  up  the 
well-established  facts  that  will  be  of  use  at  the  bedside,  or  in  the 
consulting-room.  The  minuter  pathology,  and  the  still  un- 
settled questions  regarding  the  aetiology  of  the  disease,  are  all 
discussed  at  length  in  treatises  which  are  accessible  to  you. 

Nearly  one-half  of  all  cancers,  according  to  Riegel,  involve 
the  stomach.  Hahn,  quoted  by  Boas  in  his  textbook,  gives 
the  following:  Pylorus,  35.5  per  cent.;  cardia,  23.5  per  cent.; 
lesser  curvature,  15.9  per  cent.;  greater  curvature,  4.7  per 
cent.;  diffuse  infiltration,  .12.3  per  cent.;  posterior  wall,  4.1 
per  cent. ;  anterior  wall,  4.  i  per  cent. 

Boas,  Cohnheim,  and  others  claim  that  the  lesser  curvature 
is  the  usual  point  of  origin,  the  pylorus  or  cardia  being  involved 
secondarily.  Cohnheim  explains  this  on  the  ground  that  the 
lesser  curvature  is  more  exposed  to  mechanical,  chemical,  and 
thermal  irritation  from  the  ingesta. 

Frequency  and  Incidence  of  the  Disease. — Statistics  in  Eng- 
land show  that  in  1905  one  death  in  seventeen  from  all  causes 
was  due  to  cancer,  and  it  is  shown  that  of  all  persons  reaching 
the  age  of  35  one  man  in  eleven  and  one  woman  in  8  become 
the  victims  of  cancer.  Since  at  least  one-third  of  these  can- 
cers, probably,  are  gastric,  the  frequency  of  the  disease  is  ap- 
parent, though  it  is  less  common  than  most  of  the  other  organic 
and  functional  gastric  diseases.  As  a  rule,  cancer  of  the 
stomach,  like  the  same  disease  elsewhere,  does  not  often  oc- 
cur before  middle  age,  being  rare  under  thirty;  yet  it  is  im- 

602 


CARCINOMA   OF   THE   STOMACH  603 

portant  for  you  to  bear  in  mind  that  exceptional  cases  have 
been  encountered  in  children,  and  even  in  infancy,  so  that  there 
is  always  the  possibility  that  a  doubtful  tumor,  even  in  the 
young,  may  be  malignant.  The  two  sexes  are  about  equally 
subject  to  this  disease. 

As  to  its  aetiology,  not  much  can  yet  be  said  with  certainty, 
but  the  large  amount  of  active  research  being  made  by  numer- 
ous cancer  commissions  and  individuals  gives  great  hope  of  the 
early  solution  of  the  problem.  Heredity  seems  to  be  a  factor, 
but  this  point  is  doubtful.  The  question  of  infectious  origin 
is  still  unsettled;  some  modern  workers  of  high  authority  claim 
that  the  parasitic  theory  is  refuted,  others  that  it  is  substan- 
tiated. Traumatisms  or  irritations  frequently  seem  to  exert  a 
causative  influence,  and  gastric  ulcer  stands  in  frequent 
setiologic  relation  to  cancer. 

The  Varieties  of  Cancer  which  may  affect  the  stomach  are : 

1.  Medullary  carcinoma.  2.  Scirrhous  cancer.  3.  Adeno- 
carcinoma, or  destructive  adenoma.  4.  Colloid  or  gelatinous 
cancer.     5.   Squamous  epithelial  cancer. 

Scirrhus  is  the  form  most  frequently  encountered  in  the 
stomach,  comprising,  according  to  Brinton,  ^2.  per  cent,  of  all 
gastric  cancers. 

Pathology. — 1.  Medullary  or  soft  cancer  involves  the  gas- 
tric glands,  and  while  rich  in  cells  (cancer  nests),  it  is  poor  in 
stroma.  It  is  the  predominance  of  cells  over  the  connective 
tissue  that  imparts  to  this  form  of  cancer  its  soft  structure.  It 
usually  occurs  as  a  soft  fungus  or  rounded  swelling  about  the 
pylorus.  As  the  tumor  grows,  the  blood  supply  becomes  les- 
sened, the  nutrition  impaired,  and  the  central  portions  of  the 
growth  become  softened  and  undergo  necrosis.  This  gives 
rise  to  the  formation  of  large  ulcers  with  raised  borders,  which 
distinguish  them  from  peptic  ulcers.  The  floor  of  the  ulcer  is, 
as  a  rule,  indurated  and  infiltrated  with  round  cells.  Hemor- 
rhages are  common  in  this  form  of  cancer,  and  metastases  are 
numerous.  It  often  happens  that,  owing  to  destruction  of  the 
cell-nests  and  proliferation  of  the  connective  tissue  stroma,  a 


6o4 


THE    GA5TRO-IXTE5TIXAL    CLINIC 


soft  cancer  becomes  hard  and  shrunken,  thus  changing  into  a 
scirrhous  cancer. 

2.  A  scirrhous  cancer  is  made  up  of  a  relatively  small 
number  of  cells  and  a  large  amount  of  connective  tissue  stroma. 
It  appears  in  the  form  of  a  diffuse  thickening  of  all  the  layers 
of  the  stomach  wall.  It  involves  more  especially  the  pylorus, 
which  then  becomes  obstructed,  giving  rise  to  dilatation.   There 


I- 


■'\ 


V 


>K- 


l\ 


?a 


Fig.  75.  — Cancer  of  the  posterior  wall  of   the  stomach.     (From   Sidney 
Martin's  "  Diseases  of  the  Stomach.") 

is  a  general  fibrous  hyperplasia.  The  mucous  membrane  is 
thickened,  and  the  submucosa  and  muscularis  particularly  in- 
durated. This  form  of  cancer  is  with  difficulty  diagnosticated 
from  inflammatory  thickening  or  sarcoma. 

In  scirrhus  of  the  body  of  the  stomach  the  viscus  may  be 
greatly  contracted,  but  when  it  involves  especially  the  pylorus, 
stenosis  and  dilatation  occur. 

3.  Adenocarcinoma  arises  in  mucous  membranes  covered 
with  cylindric  epithelium.  In  this  form  of  cancer  the  glandu- 
lar epithelium  proliferates,  forming  tubular  gland-like  struc- 
tures.    In  the  stomach  it  forms  soft  nodular  growths,  which 


CARCINOMA    OF    THE    STOMACH  605 

eventually  break  down  and  ulcerate.  The  stroma  is  scanty  and 
infiltrated  with  leucocytes.  The  base  of  the  ulcerated  growth 
is  almost  always  indurated  and  thickened  by  fibrous  hyper- 
plasia. 

4.  Colloid  cancer,  or  as  it  is  sometimes  called,  alveolar  can- 
cer, consists  essentially  of  an  infiltration  of  the  neoplasm  with 


^  f  ,^^\ 


I- 


Fig.  76. — Diffuse  cancer  of  the  stomach.     (From  Sidney  Martin's  "Dis- 
eases of  the  Stomach.") 

a  colloid  substance  (pseudo-mucin).  The  growth  forms  nod- 
ular swellings  or  a  diffuse  wide-spread  infiltration.  It  in- 
\olves  all  the  coats  of  the  stomach,  and  frequently  spreads  to 
the  peritoneum  and  neighboring  organs.  Ulceration  is  un- 
common. This  form  of  cancer  usually  occurs  in  young  persons. 

5.  Sqiianious  epithelioma  is  rare  in  the  stomach.  When  it 
does  occur,  it  affects  the  cardiac  end  and  the  neighboring  parts 
of  the  esophagus. 

The  secondary  pathologic  manifestations  in  gastric  cancer 


6o6  THE    GASTRO-INTESTINAL    CLINIC 

include  the  cachexia  and  metastases.  The  cachexia  is  brought 
about  by  the  disturbed  nutrition  due  to  inanition,  as  well  as  by 
the  toxic- products  of  the  cancer  itself.  It  is  noteworthy  that 
Adamkevitch  isolated  from  the  cancer  juice  a  toxic  ptomain, 
cancroin,  identical  with  cadaverin. 

The  metastases  involve  the  lymphatic  glands,  and  other 
organs,  especially  the  liver. 

The  blood  in  gastric  cancer  is  greatly  impoverished,  the 
number  of  red  blood  corpuscles  being  reduced  in  advanced 
cases  to  1,500,000  per  c.mm.  The  red  corpuscles  show  the 
poikilocytosis  of  a  grave  anjemia.  Clerc  and  Gy  ^  claim  that 
idiopathic  pernicious  anaemia  is  waning  as  an  entity,  the  blood 
picture  being  frequently  secondary  to  latent  carcinoma  (or 
other  cause),  though  there  is  nothing  in  the  blood  findings  to 
distinguish  it  from  true  pernicious  anaemia.  The  leucocytes 
are  increased  and  the  normal  hyperleucocytosis  which  occurs 
after  digestion  is  as  a  rule  absent.  The  hemoglobin  is  de- 
creased in  proportion  to  the  anaemia. 

Complications,  Sequels,  etc. — Gastric  cancer  involving  the 
orifices  causes  organic  changes  in  them  usually  of  an  obstruc- 
tive character,  or  less  frequently  by  a  process  of  infiltration 
stiffens  them  in  such  a  manner  that  the  muscular  fibers  are  no 
longer  able  to  contract. 

Cancerous  stenosis  of  tJie  pylorus  produces  dilatation  of  the 
stomach,  which  often  attains  finally  an  enormous  size,  filling 
in  some  instances  nearly  the  entire  abdominal  cavity.  This 
results  in  the  peculiar  periodic  vomiting  described  further  on, 
of  very  large  quantities  of  offensive,  decomposing  ingesta. 

Obstruction  of  the  cardia  by  a  cancerous  growth,  or  ob- 
struction in  like  manner  of  the  esophagus,  produces  a  gradual 
contraction  of  the  stomach  until  at  death  the  latter  may  hold  a 
few  ounces  only,  the  esophagus  dilating  above  the  stricture. 

Diffuse  scirrhus  of  the  gastric  zvalls  may  also  cause  a  sim- 
ilar contraction. 

An  unyielding  non-contractile  condition  of  the  circular  mus- 

"^  Arch,  des  Maladies  du  Cceur,  April,  1909. 


CARCINOMA    OF    THE    STOMACH  607 

cular  fibers  of  the  pylorus,  due  to  a  cancerous  infiltration  with 
the  result  that  it  cannot  close,  produces,  as  a  rule,  no  noteworthy 
anatomic  changes  elsewhere  in  the  viscus,  but  aggravates  the 
impairment  of  nutrition  by  allowing  a  reflux  into  the  stomach 
of  bile  and  other  contents  of  the  small  intestine,  including  not 
infrequently  feces. 

Hour-glass  contraction  of  the  stomach  has  been  noted  in 
a  few  instances  as  a  result  of  cancer. 

Distortions  of  the  stomach  occur  very  often  in  consequence 
of  the  cancerous  process  having  involved  the  peritoneal  laver 
with  the  development  of  local  inflammation  which  produces 
adhesions  to  adjacent  organs.  There  may  exceptionally  be  per- 
foration into  the  peritoneal  cavity,  the  pleural  cavity,  or  even 
the  pericardium. 

Tetany,  which  is  referred  to  in  Lecture  XXXVII. ,  is  a  rare 
complication  of  cancer  of  the  stomach. 

Dropsy  is  a  not  uncommon  late  development,  and  coma, 
closely  similar  in  all  respects  to  diabetic  coma,  may  usher  in  the 
final  stage  of  the  disease. 

Gastrocolic  Fistula  is  scarcely  mentioned  by  most  authors, 
but  is  an  occasional  noteworthy  complication  of  gastric  cancer 
This  condition,  though  rare,  is  one  of  extreme  seriousness,  and 
it  thus  becomes  important  to  recognize  it  early  so  that  a  cor- 
rect prognosis  may  be  given,  and  in  certain  instances,  remedial 
operation  be  resorted  to. 

Aitiology. — Gastrocolic  fistula  occurs  most  frequently  as  a 
complication  of  gastric  cancer,  but  may  complicate  gastric 
ulcer  or  rarely  cancer  of  the  colon.  The  most  frecjuent  cause 
next  to  cancer  is  ulcer  of  the  stomach.  Of  the  remaining 
causes,  mention  should  be  made  of  double  perforation  of  an 
abscess,  and  the  congenital  existence  of  the  condition  which  is, 
however,  questionable. 

Symptoms. — At  the  time  of  the  perforation  the  patient  may 
complain  of  acute  pain,  but  more  frequently  experiences  the 
sensation  of  something  having  given  way.  This  may  be  fol- 
lowed by  prostration,  and  even  collapse,  as  well  as  the  appear- 


6o8  THE    GASTRO-INTESTINAL    CLINIC 

ance  in  the  vomit  of  red  blood  and  shreds  of  tissue,  the  whole 
resembling  the  vomitus  after  a  recent  attack  of  hematemesis. 

The  symptoms  vary  much  in  different  cases.  There  may 
occur,  for  instance,  cases  of  such  a  fistula  w^hich  do  not  ex- 
hibit any  positive  clinical  evidence  of  the  lesion.  Such  cases 
are  of  interest  chiefly  to  the  pathologist.  Then  you  will  en- 
counter cases  in  which  fecal  vomiting  is  a  pronounced  symp- 
tom. You  will  need  to  depend  then  upon  the  concomitant 
symptoms  to  make  a  correct  diagnosis. 

Roughly  speaking,  fecal  vomiting  occurs  in  a  fraction  over 
one-half  the  cases  observed.  Its  existence  is  not  in  any  respect 
diagnostic  of  gastrocolic  fistula,  since  it  has  been  reported  in 
a  number  of  cases  of  pyloric  cancer  in  which  the  pylorus  was 
permanently  patulous,  being  unable  to  contract ;  also  in  hys- 
teria, intestinal  obstruction,  and  some  other  conditions.  But  in 
the  absence  of  evidence  of  any  of  the  above  mentioned  affec- 
tions, fecal  vomiting  should  lead  you  to  think  at  once  of  the 
complication  now  under  consideration. 

It  comes  on  quite  suddenly,  as  a  rule,  when  due  to  gastro- 
colic fistula,  its  feculent  character  becoming  at  once  noticeable. 
The  offensive  feculent  odor,  the  brownish  color,  and  at  times 
the  presence  of  well-formed  feces  from  the  lower  bowel  make 
positive  the  nature  of  the  vomit  whenever  the  characteristic  ap- 
pearances are  present.  In  such  cases  the  breath  is  likely  to 
have  constantly  a  fecal  odor. 

There  usually  results,  also,  a  persistent  and  troublesome  lien- 
teric  diarrhea,  the  patient  passing  at  stool,  soon  after  eating, 
large  quantities  of  partially  or  wholly  undigested  food.  Thus 
the  rapid  passage  of  the  food  undigested  into  the  lower  bowel 
brings  about  a  consequent  rapid  and  marked  emaciation,  which 
is  often  out  of  all  proportion  to  the  possible  effect  of  the  exist- 
ing carcinoma.  The  patient,  as  Bouveret  states,  practically 
vomits  persistently  into  the  larger  bowel.  This  happens  es- 
pecially when  there  is  a  sudden  cessation  of  the  usual  upward 
vomiting,  the  diarrhea  developing  generally  a  short  time 
afterward. 


CARCINOMA    OF    THE    STOMACH  609 

Substances  introduced  into  the  rectum  may  sometimes  be 
found  in  the  vomit  a  very  short  time  later.  After  lavage  of 
the  stomach  it  may  be  noted  that  a  more  than  usual  decrease 
has  taken  place  in  the  amount  of  fluid  recovered,  as  compared 
with  the  amount  introduced.  This  is  out  of  all  proportion  to 
the  loss  of  liquid  after  washing  out  a  non-perforated  stomach. 
Then  the  patient  experiences  soon  afterward  a  desire  to  evacu- 
ate the  bowel. 

Inflation  of  the  stomach  may  cause  a  secondary  prominence 
over  the  colon,  although  this  result  has  not,  as  a  rule,  proved 
so  striking  as  when  the  air  is  introduced  by  way  of  the  lower 
bowel.  In  the  latter  case,  the  sigmoid,  and  at  times  the  trans- 
verse colon  may  become  sufficiently  distended  to  be  recogniz- 
able. After  such  a  distention  the  air  will  rapidly  enter  the 
stomach  and  be  followed  by  marked  eructations  of  gas  from  the 
patient's  mouth. 

In  a  case  reported  by  Edsall  and  Fife^  the  patient  presented 
many  symptoms  of  gastrocolic  fistula,  such  as  the  presence  of 
cancer  and  persistent  feculent  vomiting  especially,  and  the 
vomitus  contained  shreds  of  tissue.  Inflation  of  the  lower 
bowel  resulted  in  a  marked  belching  of  a  foul  gas,  in  consider- 
able quantities,  with  a  consequent  subsidence  of  the  distention. 
A  large  percentage  of  fat  appeared  in  the  vomit  while  the  pa- 
tient was  receiving  enemas  of  milk  and  eggs. 

The  autopsy,  however,  showed  the  pylorus  to  be  infiltrated 
with  cancer  which  had  converted  it  into  a  firm  non-contract- 
ing patulous  tube.     No  fistula  was  to  be  found. 

Symptomatology  of  Gastric  Carcinoma. — Cancer  of  the 
stomach  usually  begins  with  the  symptoms  of  chronic  gastric 
catarrh,  mildly  and  often  very  insidiously.  It  is  quite  impos- 
sible to  make  the  diagnosis  at  first.  When,  however,  a  person 
of  middle  age  or  beyond,  who  has  not  previously  suffered  from 
indigestion,  begins,  without  any  particular  fault  in  diet,  to 
complain  of  slight  discomfort  after  eating,  with  gaseous  eruc- 
tations, falling  off  in  appetite,  especially  for  meats  and  fats,  and 
'  Am.  Med.,  October  10,  1903,  p.  584. 


6lO  THE    GASTRO-INTESTINAL    CLINIC 

loss  of  strength,  these  symptoms  persisting  and  becoming  grad- 
ually and  often  rapidly  worse,  in  spite  of  appropriate  treat- 
ruent,  you  may  suspect  carcinoma.  If,  then,  the  usual  tests 
should  show  a  diminished  percentage  of  HCl,  and  still  more 
if  there  should  be  found  constantly  a  failure  of  free  HCl  and 
the  presence  of  much  lactic  acid  during  the  period  of  digestion, 
together  with  a  progressive  impairment  of  motor  power  in  the 
stomach  walls,  with  or  without  the  development  of  cachexia, 
the  likelihood  of  a  malignant  process  would  be  considerable. 

The  above-named  symptoms,  even  w^th  nausea,  copious 
vomiting,  and  pain  in  the  stomach  added,  would  not  be  conclu- 
sive as  to  the  existence  of  carcinoma,  since  chronic  asthenic 
or  atrophic  catarrh,  with  dilatation  from  myasthenia  or  from 
any  of  the  benign  forms  of  obstruction  of  the  pylorus,  might  ac- 
count for  all  of  them.  If,  however,  in  addition  to  such  a  group 
of  symptoms  growing  worse  in  spite  of  good  treatment,  there 
should  appear  vomitings  of  blood,  or  coffee-ground  matter  in 
either  the  vomit  or  stools,  and  the  pain  should  increase  and  be- 
come fairly  constant  without  regard  to  the  digestive  periods,  es- 
pecially if  lactic  acid  should  be  found  in  the  proportion  of  i  to 
looo,  with  or  without  the  Boas-Oppler  bacilli,  there  would  be 
sufficient  cause  for  venturing  the  diagnosis  of  probable  cancer, 
and  advising  an  exploratory  incision,  even  before  a  tumor 
could  be  recognized. 

But  you  will  rarely  find  all  these  typical  symptoms  in  any 
one  case — at  all  events  rarely  before  a  tumor  has  become  mani- 
fest. Even  when  all  or  most  of  them  are  present,  there  is  by 
no  means  always  the  typical  progressive  downward  course. 
Under  suitable  treatment,  there  are  often  short  periods  of  im- 
provement which  tend  to  awaken  false  hopes  and  sometimes 
shake  the  faith  of  even  the  doctor  himself  as  to  the  correctness 
of  his  own  diagnosis.  The  pain  may  be  referred  to  any  part 
of  the  region  usually  occupied  by  the  stomach,  or  far  below  the 
navel,  as  the  organ,  by  dilatation  or  displacement,  not  infre- 
quently extends  into  the  pelvis.  It  may  radiate  to  either  hypo- 
chondrium  or  to  the  back,  and  may  be  felt  in  the  left  shoulder, 


CARCINOMA   OF  THE   STOMACH  6ll 

especially  when  the  cardia  is  involved.  It  is  generally  dull, 
though  there  may  be  acute  exacerbations.  Its  most  marked  pe- 
culiarity is  its  relative  constancy,  as  compared  with  the  inter- 
mitting pains  of  other  gastric  diseases. 

Vomiting  is  an  extremely  frequent  symptom,  and  when,  as  is 
most  usual,  the  growth  causes  pyloric  obstruction,  with  result- 
ing dilatation  and  stagnation,  it  is  peculiar  and  characteristic. 
The  vomiting  is  then  apt  to  come  on  every  second  or  third  day, 
when  large  amounts  of  undigested  and  partly  decomposed  gas- 
tric contents  will  be  brought  up,  in  which  there  may  be  yeast 
germs,  the  Boas-Oppler  bacilli,  changed  blood  and  possibly  pus, 
as  well  as  much  mucus,  but  rarely  sarcinse.  When  the  cancer 
is  near  the  cardia,  vomiting  is  apt  to  occur  more  frequently  and 
rather  soon  after  the  taking  of  food.  Fever  is  included  by 
some  writers  among  the  symptoms  of  gastric  cancer,  but  is 
only  exceptionally  present  and  then  usually  toward  the  end  of 
the  disease.  Constipation,  another  alleged  symptom  of  cancer, 
is  often  replaced  by  diarrhea,  and  it  prevails  also  in  most  other 
diseases  of  the  stomach.  Anorexia,  debility,  and  emaciation 
all  develop  more  uniformly  and  rapidly,  as  a  rule,  than  in  other 
gastric  affections,  and  cachexia  shows  itself  certainly  at  some 
stage,  though  not  often  to  a  marked  extent,  long  before  a  tumor 
can  be  recognized. 

The  most  constant  signs  during  the  first  six  months,  or 
before  a  tumor  can  be  felt,  are  a  peculiarly  dirty  tongue,  fail- 
ing appetite,  flesh,  strength,  and  color,  and,  when  the  growth 
involves  the  pylorus,  the  evidences  of  gastric  dilatation,  in- 
cluding a  splashing  sound  obtained  by  tapping  over  the  stom- 
ach, or,  when  this  fails,  by  detecting  the  splash  of  the  retained 
gastric  contents  by  palpation,  while  the  patient  is  caused  to 
contract  the  diaphragm  by  his  own  efforts.  Such  a  splash, 
either  heard  or  felt  over  the  region  occupied  by  the  organ,  sig- 
nifies weakened  stomach  walls,  as  well  as  the  presence  at  once 
of  liquid  and  gas  produced  by  fermentation;  when  heard  or 
felt  below  the  umbilicus,  it  means  that,  whether  there  be  can- 
cer or  not,  there  exists  a  dilatation  or  displacement  of  the 


6l2  THE    GASTRO-INTESTINAL    CLINIC 

stomach,  if  the  other  signs  show  that  the  latter  extends  that 
far.  Neither  of  these  signs  is  diagnostic,  and  the  splash  may 
^e  elicited  in  merely  atonic  or  displaced  stomachs.  After 
cathartics  or  enemas,  or  even  without  these,  fluid  and  gas  in 
the  transverse  colon  may  cause  confusion  by  giving  a  well- 
marked  splash.     This  must  be  excluded. 

We  know,  also,  that  the  absence  of  free  HCl,  and  even  the 
presence  of  a  considerable  proportion  of  lactic  acid,  are  not 
pathognomonic  of  carcinoma,  though  lactic  acid,  in  the  pro- 
portion of  I  to  looo  or  above,  when  the  test  breakfast  has  been 
given  as  directed  by  Boas,  consisting  of  oatmeal  or  barley  gruel 
without  milk  or  cream,  and  preceded  the  evening  before  by  a 
thorough  lavage,  affords  strong  presumptive  evidence  of  can- 
cer, being  only  very  exceptionally  found  in  other  conditions, 
such  as  aggravated  cases  of  asthenic  gastric  catarrh,  with  great 
stagnation  of  the  stomach  contents.  A  shredded-wheat  biscuit 
and  ten  ounces  of  hot  water  or  clear  tea  constitute  a  convenient 
lactic-acid-free   test  breakfast. 

But  the  absence  of  free  HCl  of  itself  need  not  even  raise  a 
suspicion  of  cancer.  Samples  of  stomach  contents  without 
free  HCl  are  examined  almost  daily  in  my  laboratory  from 
patients  with  various  non-malignant  troubles,  especially 
asthenic  and  atrophic  catarrhs  and  some  of  the  neuroses  of  the 
stomach.  On  the  other  hand,  the  presence  of  a  full  or  normal 
percentage  of  free  HCl  does  not  preclude  the  existence  of 
cancer,  especially  that  form  which  arises  in  the  site  of  an  ulcer. 

The  sediment  of  the  wash  water  after  lavage  should  be 
studied  to  ascertain  whether  there  are  present  fragments  which 
show  the  cancer  cells  or  the  histologic  structure  peculiar  to  car- 
cinoma, the  Boas-Oppler  bacilli,  microscopic  food  remnants, 
pus  or  blood.  The  first  named  probably  constitute  the  most 
certain  of  the  earlier  signs  of  gastric  carcinoma,  though  fail- 
ure to  find  them  by  no  means  excludes  the  possibility  of 
malignancy. 

Hemmeter  reports  having  obtained  positive  evidences  of  the 
existence  of  a  malignant  growth  in  the  stomach  from  the  pe- 


CARCINOMA  OF  THE  STOMACH 


613 


culiar  character  and  arrangement  of  the  cells,  one  to  three 
months  before  a  tumor  could  be  felt.  His  method  in  suspected 
cases  is  to  feed  by  the  rectum  exclusively  for  forty-eight  hours, 
then  wash  out  the  stomach  with  the  normal  salt  solution,  using 
for  this  purpose  a  soft  rubber  tube  provided  with  edges  of  un- 
usual firmness  around  the  lower  opening,  so  as  to  facilitate  the 
dislodgment  of  fragments  of  the  tumor. 

As  to  the  Boas-Oppler 
bacilli,  while  their  presence 
would  not  alone  warrant  a 
positive  diagnosis  of  cancer, 
or  their  absence  exclude  it, 
they  constitute  one  of  the 
most  valuable  confirmatory 
signs,  especially  when  they 
are  very  plentiful.  They 
are  long,  filiform,  and  non- 
motile  bacihi,  abundantly 
forming  lactic  acid  from 
sugar.  They  stain  yellow 
with  Gram's  stain,  while  the  leptothrix  stains  purple. 

In  the  terminal  stage  of  gastric  cancer,  there  is  likely  to  be, 
along  with  extreme  emaciation  and  prostration,  dropsy  of  the 
extremities,  and  coma, — the  coma  carcinoniatosiiiu. 

Symptoms  of  Cancer  as  Affected  by  its  Location. — The 
foregoing  account  of  the  symptoms  applies  especially  to  the 
most  prevalent  forms  of  gastric  cancer,  in  which  the  growth 
has  originated  in  or  near  the  pylorus,  where  it  sooner  or  later 
obstructs  the  onward  passage  of  the  food  into  the  bowel.  In 
these  cases  the  tumor  at  first,  before  dilatation  has  taken  place, 
occupies  a  position  just  to  the  right  of  the  middle  line,  where 
it  is  covered  by  the  liver,  except  when  there  has  been  previously 
an  enlargement  or  downward  displacement  of  the  organ.  It  is 
always  difficult,  and  often  impossible,  to  palpate  the  tumor  in 
this  position,  but  later,  when  the  inevitable  dilatation  has  re- 
sulted, it  appears  below  the  liver  and  is  more  easily  within 


Fig.  77. — Boas-Oppler  bacilli. 


6i4 


THE    GASTRO-INTESTINAL    CLINIC 


reach  of  the  examining  fingers,  except  when  the  stomach  is  ad- 
herent to  the  left  lobe  of  the  liver.  Indeed,  in  some  cases  the 
growth  may  be  felt  below  the  level  of  the  umbilicus. 

Cancer  of  the  Cardia. — When  the  disease  involves  primarily 
the  cardiac  orifice  the  clinical  picture  is  very  different.  The 
first  complaints  then  are  usually  of  difficulty  in  swallowing, 
and  of  the  regurgitation  of  food  which  has  failed  to  pass  the 
obstruction.     The  patient  is  conscious  of  a  stoppage  in  the 


Fig.  78.— Cancer  of  the  pylorus.     (From   Sidney  Martin's  "  Diseases  of 

the  Stomach.") 

lower  part  of  the  esophagus,  and  of  the  necessity  of  taking  an 
unusually  large  amount  of  fluid  to  facilitate  the  passage  of  the 
swallowed  bolus  into  his  stomach.  There  is  emaciation,  in 
spite  of  possibly  at  first  a  good  appetite  and  fairly  full  feeding. 
The   stomach  contracts,   and  may  become  very  small.     The 


CARCINOMA  OF  THE  STOMACH 


615 


esophagus  dilates.  The  matters  ejected  contain  undigested 
ahment  with  saHva,  mucus,  and  often  blood,  but  no  HCl  or 
gastric  ferments.  An  abundant  bacterial  flora  is  present,  in- 
cluding frequently  Boas-Oppler  bacilli.  There  is  pain  re- 
ferred to  the  site  of  the  cardia  or  sometimes  to  the  back  op- 
posite.    The  obstruction  at  the  cardia  may  usually  be  easily 


\- 


Fig.  79.— Cancer  of  the  cardia,     (From  Sidney  Martin's  "  Diseases  of  the 

Stomach.") 

recognized  by  the  use  of  stomach  tubes  or  esophageal  bougies 
of  graduated  sizes. 

In  doubtful  cases,  to  decide  whether  food  is  retained  in  the 
esophagus,  you  should  first  introduce  a  large  stomach  tube  as 
far  as  it  will  go,  noting  the  point  where  it  is  arrested,  and  then, 
with  the  help  of  a  Kuttner  aspirator,  inserted  in  the  tube  (a 
cut  of  this  instrument  is  shown  on  page  114),  bring  up  what- 
ever will  come.     Afterward  pass  into  the  stomach  through  the 


6l6  THE    GASTRO-INTESTINAL    CLINIC 

Stricture,  if  possible,  a  smaller  tube,  and  extract  some  of  the 
contents  in  the  same  manner. 

V  If  the  contents  first  obtained  were  coarse,  undigested,  and 
free  from  peptones,  HCl,  or  the  usual  gastric  ferments,  while 
those  obtained  with  the  smaller  tube  are  different,  the  fact  of 
retention  in  the  esophagus  would  be  established. 

A  stenosis  of  the  cardia  determined  positively  by  such  in- 
strumental methods,  taken  in  connection  with  localized  pain, 
steadily  failing  strength  and  flesh,  and  the  development  of  a 
cachexia  would  justify  a  diagnosis  of  cancer  in  that  region. 
Another  sign  of  some  confirmatory  value  is  a  delay  of  ten  to 
fifteen  seconds  in  the  time  of  hearing  the  gurgling  sound  which 
is  normally  heard  about  seven  seconds  after  swallowing  liquids. 
To  recognize  this,  you  should  place  the  stethoscope  over  the 
region  of  the  cardia  and  hold  it  there  while  the  patient 
swallows. 

Benign  stricture  should  be  excluded.  Here  there  is  usu- 
ally a  definite  history  of  caustics  swallowed  or  a  lacerating 
foreign  body;  the  course  of  the  disease  is  commonly  slower 
and  the  loss  of  flesh  and  strength  less  extreme.  Blood  and 
pus  are  less  likely  to  be  present  in  the  ejecta.  Cardiospasm,  or 
spasm  of  the  esophagus,  is  usually  found  in  young  neurotic 
individuals.  The  onset  may  be  sudden.  The  stenosis  is  apt 
to  vary  from  day  to  day,  fluids  being  taken  with  difficulty  at 
one  time,  and  coarse  solids  easily  swallowed  soon  after.  A 
large-caliber  bougie  passes  the  stricture  as  freely,  or  more  so, 
than  a  small  one;  and  all  obstruction  disappears  under 
anesthesia. 

In  cancer  of  the  body  of  the  stomach  the  organ  does  not 
usually  dilate  (though  it  will  often  be  found  to  have  been  en- 
larged before),  and  it  may  even  contract.  The  vomiting, 
therefore,  will  seldom  be  of  such  large  quantities  of  stagnant 
contents  as  when  the  growth  involves  the  pylorus,  but  the 
pain,  cachexia,  hemorrhages,  and  other  symptoms  are  very 
similar. 

Hemorrhage  from  a  gastric  cancer  may  not  reveal  itself  by 


SARCOMA    OF   THE    STOMACH  617 

the  vomiting  of  blood,  but  in  such  cases,  besides  the  appearance 
of  altered  blood  in  the  stools,  there  will  be  usually  such  symp- 
toms as  pallor  and  weakness,  or  dizziness  when  the  loss  has 
been  large — possibly  fainting  or  collapse. 

SARCOMA   OF   THE    STOMACH 

Sarcoma  of  the  stomach  being  so  rare  a  disease,  and  usually 
not  to  be  diagnosed  from  carcinoma,  its  pathology  is  of  com- 
paratively little  interest  or  importance  to  clinicians.  It  may  be 
primary  or  secondary  and  may  affect  any  part  of  the  viscus, 
though  it  is  most  likely  to  be  found  on  the  greater  curvature. 
With  the  exception  of  the  lymphosarcoma  the  secondary  form 
is  even  less  frequent  than  the  primary. 

The  varieties  of  sarcoma  which  have  been  described  by  gas- 
trologists  are  the  spindle-celled,  the  round-celled,  including 
lymphosarcoma,  angiosarcoma,  myosarcoma,  and  fibrosar- 
coma. 

-Etiology,  Incidence,  etc — We  know  no  more  as  to  the 
origin  of  sarcoma  than  of  carcinoma,  except  that  it  often  oc- 
curs in  a  part  which  has  been  subjected  to  repeated  irritation 
or  injury. 

It  affects  both  sexes  about  equally,  so  far  as  has  been  ob- 
served. Some  of  the  forms  of  sarcoma,  especially  primary 
lymphosarcoma,  according  to  Schlesinger,  may  appear  at  any 
age,  but  oftenest  in  the  young — between  the  ages  of  twenty 
and  thirty-five  years.  The  same  author  holds  that  the  other 
forms,  contrary  to  the  prevailing  opinion,  are  rather  more 
likely  to  occur  in  the  old  than  in  the  young. 

Symptoms  and  Diagnosis. — As  with  cancer  of  the  stomach, 
sarcoma  usually  begins  insidiously,  and,  especially  when  there 
is  a  diffuse  infiltration  of  the  greater  curvature  or  body  gen- 
erally, may  for  some  time  remain  without  symptoms.  In  other 
cases  you  will  observe  the  same  symptoms  already  described  as 
occurring  in  carcinoma.  In  these  typical  cases  both  the  local 
gastric  and  the  general  or  constitutional  symptoms  may  be  ex- 
pected, even  to  the  vomiting  of  blood  or  altered  blood,  though 


6l8  THE    GASTRO-INTESTINAL    CLINIC 

this  symptom  would  seem  to  be  less  frequent  than  in  the  case 
of  cancer.  Fever  and  persistent  albuminuria  point  rather  to 
s?^rcoma  (Fenwick^). 

There  may  be  dilatation  of  the  stomach  with  all  its  serious 
train  of  consequences,  including  sometimes  tetany,  when  the 
sarcoma  involves  the  pylorus  in  such  a  way  as  to  produce 
stenosis;  and  lymphosarcoma  is  said  to  be  capable  of  produc- 
ing dilatation,  even  without  having  obstructed  the  pylorus. 

The  chemical  findings  difTer  in  no  essential  respect  from 
those  present  in  cases  of  gastric  cancer 

Schlesinger  emphasizes  certain  points,  however,  as  useful  in 
making  the  differential  diagnosis :  Swelling  of  the  spleen  is 
more  frequent  in  sarcoma,  and  there  is  a  greater  tendency  to 
develop  metastasis  in  the  intestines  as  well  as  in  the  skin,  where 
various-sized  nodules  may  frequently  be  found.  Metastasis 
in  the  pericardium  has  been  reported.  As  the  disease  does  not 
generally  cause  stenosis  of  the  gut,  it  may,  therefore,  be  in- 
ferred, when  a  tumor  of  the  stomach  produces  a  metastatic 
growth  in  the  bowels  without  obstructing  them,  that  it  is  sar- 
comatous rather  than  carcinomatous. 

Sarcoma  usually  grows  faster  and  is  likely  to  attain  a  much 
larger  size  than  cancer.  The  tumor  usually  is  smoother — not 
knobbed  or  nodulated  as  a  rule.  And,  if  its  more  frequently 
observed  course  in  the  bowels  can  be  accepted  as  a  criterion,  it 
kills  sooner  than  cancer  of  the  stomach.  The  fatal  result  may 
occur  within  less  than  a  year,  though  Riegel  is  authority  for 
the  statement  that  it  may  be  exceptionally  delayed  as  long  as 
three  years. 

Except  for  the  fact  of  its  more  rapid  course,  it  would  seem 
of  little  clinical  importance  to  make  the  diagnosis  of  sarcoma 
from  carcinoma  of  the  stomach. 

BENIGN   TUMORS   OF   THE   STOMACH 

These    include   myoma,    fibroma,    lipoma,    papilloma,    cyst, 
and  lymphadenoma,  the  first  four  of  which  tend  to  produce 
polypi.     These  are  practically  never  recognized  in  the  stomach 
1  Cancer  and  Other  Tumors  of  the  Stomach,  p.  280. 


BENIGN    TUMORS    OF    THE    STOMACH  619 

during  life,  and  they  are,  therefore,  of  very  trifling  cHnical  im- 
portance. A  few  cases,  however,  are  on  record  in  which  such 
growths  have  been  the  cause  of  symptoms — pain,  vomiting, 
and  even  hematemesis,  and  very  exceptionahy  obstruction  of 
the  pylorus  with  dilatation.  In  any  anomalous  case,  therefore, 
which  may  confront  you,  it  is  well  to  remember  that  such 
symptoms  can  possibly  arise  from  a  no  more  serious  cause. 

Lymphadenoma. — Lymphoid  tumors  in  the  stomach,  though 
exceedingly  rare,  have  by  extension  to  various  other  organs, 
including  the  spleen  and  intestines,  been  known  to  result  in 
death.  Nodules  were  found  scattered  through  the  afifected 
parts,  and  diarrhea  was  among  the  symptoms  noted. 

Foreign  Bodies  in  the  Stomach. — Hysteric  women  will  oc- 
casionally swallow  enough  of  their  hair  to  produce,  in  time, 
palpable  and  movable  tumors  in  the  stomach.  Numerous  cases 
of  the  kind  are  on. record,  in  some  of  which  the  diagnosis  of 
cancer  has  been  made.  Serious  failure  of  health  results  and 
continues  till  the  tumor  is  removed. 

The  swallowing  of  knives  or  other  objects,  in  imitation  of 
jugglers,  has  been  responsible  for  other  factitious  tumors  in 
the  stomach.  In  a  few  instances,  also,  indigestible  portions  of 
food  seem  to  have  been  agglutinated  into  a  hard  mass  which  re- 
mained in  the  stomach  with  the  result  of  producing  a  palpable 
tumor,  which  mechanically  impaired  digestion  and  injured  the 
general  health.  Any  such  tumor  should  be  easily  diagnosed 
by  its  perfect  mobility. 

Treatment. — None' of  the  benign  tumors  or  foreign  bodies 
in  the  stomach  are  amenable  to  other  than  surgical  treatment. 
In  any  such  case  in  which  a  tumor  is  palpable,  an  exploratory 
incision  should  be  made  with  a  view  to  a  prompt  removal  of 
the  offender  whenever  practicable. 

Thickening  of  the  Pylorus. — Under  various  conditions  a 
thickening  or  swelling  of  the  pylorus  can  occasionally  be  made 
out  by  palpation,  when  no  malignant  growth  exists.  This  gen- 
erally coincides  with  a  stenosis  of  the  pyloric  outlet  with  con- 
sequent obstruction  and  dilatation  of  the  stomach.     Indeed  the 


620  THE    GASTRO-INTESTINAL    CLINIC 

obstruction  of  the  outlet  is  primary,  and  the  thickening  of  the 
muscles  a  result.  It  is  easily  intelligible  that,  whatever  the 
cause  of  the  stenosis,  the  consequences  to  the  stomach  are  much 
the  same,  though  in  cancer  or  sarcoma  there  is  an  added  cause 
of  rapid  failure  of  health. 

The  most  frequent  origin  of  a  non-malignant  thickening  or 
resistance  felt  in  the  pyloric  region  is  the  cicatrix  of  a  healed 
ulcer.  This  subject  is  discussed  in  Lecture  LII.  in  connection 
with  the  sequels  of  gastric  ulcer.  Such  a  swelling  is  small  and 
elongated  or  oval  in  form,  and  is  frequently  immovable.  When 
the  stomach  is  in  normal  position  and  of  normal  size,  such  a 
tumor  cannot  be  felt — at  least  until  after  the  viscus  has  been 
strongly  inflated — because  of  its  being  covered  by  the  left  lobe 
of  the  liver.  But  in  displacement,  and  in  dilatation,  of  the  stom- 
ach, one  or  both  of  which  nearly  always  develops  soon  after 
the  occurrence  of  an}^  mechanical  obstruction  of  the  pylorus,  the 
thickened  pylorus  may  often  be  felt,  especially  in  thin  persons, 
just  to  the  right  of  the  median  line,  and  somewhere  at  or  below 
the  level  of  the  navel. 

Hypertrophic  stenosis  of  the  pylorus  resulting  from  the  pro- 
liferative form  of  gastritis  has  been  described  by  Boas  and 
others.  This  is  another  condition  in  W'hich  there  is  obstruction 
of  the  gastric  outlet,  with  sometimes  a  sufficient  amount  of  re- 
sulting swelling  of  the  mucous  membrane  and  hypertrophy  of 
the  muscularis  to  form  a  palpable  tumor. 

The  diagnosis  of  all  such  pyloric  hypertrophies  is  from 
cancer  of  the  pylorus,  which  is  by  all  odds  the  most  frequent 
cause  of  a  tumor  in  this  region.  In  cancer,  beside  the  compara- 
tively rapid  loss  of  flesh,  strength,  and  color,  with  the  develop- 
ment usually  of  cachexia,  there  are  certain  local  peculiarities  in 
the  tumor  which  help  to  differentiate  it  from  a  thickened  and 
swollen  pylorus. 

The  latter  is  usually  small  and  narrow  as  well  as  smooth, 
while  carcinoma  is  likely  to  develop  irregularly,  producing  a 
nodular  swelling,  and  moreover,  soon  grows  to  a  much  larger 
size  than  the  benign  form  of  swelling  ever  attains. 


LECTURE  LX 

THE    DIAGNOSIS    OF   CARCINOMA   OF 
THE    STOMACH 

There  should  be  no  difficulty  in  recognizing  a  typical  cancer 
of  the  stomach,  when  the  tumor  is  palpable.  The  diagnosis 
can  then  be  made  certainly  from  the  unevenness  of  the  growth, 
its  mobility,  as  a  rule,  and  its  association  with  the  symptoms  de- 
scribed in  the  previous  lecture,  especially  the  presence  of  pain, 
which  is  more  or  less  constant,  cachexia,  anorexia,  and  vomit- 
ing, with  the  occasional  appearance  in  the  vomited  matter  as 
well  as  in  the  stools,  of  blood,  usually  in  small  amounts  and 
of  dark  altered  appearance,  or  occult;  but  sometimes  in  larger 
quantity,  when  it  may  be  bright  red.  Further  diagnostic 
points  are  the  characteristic  chemic  and  microscopic  findings 
previously  described,  the  marked  insufficiency  of  the  gastric 
muscular  power  and  the  comparatively  rapid  and  usually  pro- 
gressive loss  of  strength  and  flesh,  the  muscular  tissues  being 
lost  faster  than  the  fatty — ^just  the  contrary  from  what  hap- 
pens in  tuberculosis. 

But  it  is  exceedingly  important  to  make  the  diagnosis  of 
gastric  carcinoma  at  the  earliest  possible  moment  and  before  a 
tumor  can  be  made  out.  Often  when  a  tumor  is  palpable,  the 
time  for  operation  has  already  gone  by. 

It  is  your  duty  to  make,,  or  have  made  for  you,  a  probable 
diagnosis  in  such  cases  at  a  time  when,  if,  after  an  exploratory 
incision,  cancer  be  found,  an  operation  can  be  done  with  the 
reasonable    hope    of    at    least    considerably    prolonging    life. 

You  should  consider  the  possibility  of  cancer  or  some  other 
important  lesion  in  the  case  of  every  patient  whose  dyspepsia, 
especially  if  recently  accjuired,  does  not  within  a  week  or  two 

621 


622  THE    GASTRO-IXTESTINAL    CLINIC 

show  improvement  after  a  proper  regulation  of  the  diet  and 
hygiene  generally,  and  a  trial  of  simple  remedies.  The  history 
should  be  patiently  taken  in  full  detail.  Repeated  physical  ex- 
aminations should  be  made,  especial  pains  being  taken  to  de- 
tect a  possible  tumor  or  enlarged  glands;  an  enlarged  gland 
above  the  left  clavicle  behind  the  margin  of  the  sterno-mastoid 
is  said  to  occur  in  about  15  per  cent,  of  the  cases.  You  ought 
then  to  test  the  stomach  contents  and  gastric  motility.  If, 
with  increasing  debility,  emaciation,  and  anaemia,  you  find  free 
HCl  absent,  or  present  in  very  low  percentage,  or  steadily  fail- 
ing; if  you  find  lactic  acid  present  in  considerable  amount,  such 
as  a  proportion  of  i  in  1000  or  higher,  after  a  Boas  test  meal, 
which  contains  no  milk  products,  and  if  you  find  occult  blood 
occasionally  in  the  stomach  contents  or  stools,  the  case  becomes 
very  suspicious,  and  you  would  be  justified  in  summoning  a 
surgeon  at  once  to  consider  the  propriety  of  an  exploratory  in- 
cision. Before  resorting  to  surgery,  however,  you  should 
make  a  microscopic  examination  of  the  sediment  of  the  wash- 
water,  after  morning  lavage  of  the  fasting  stomach;  this  ex- 
amination requires  patience  and  skill,  but  it  will  often  furnish 
important  corroborative  evidence,  and  sometimes  warrant  a 
certain  diagnosis.  This  certain  diagnosis  can  be  reached  only 
when  you  find  undoubted  fragments  of  the  tumor,  showing 
nests  of  cancer  cells  or  other  characteristic  structure  of  carci- 
noma. Such  satisfactory  results  are  certainly  rare,  but  they 
would  probably  be  much  less  so  if  we  were  willing  to  give 
the  time  and  patience  necessary  to  the  search.  I  agree  with 
Hemmeter  that,  considering  the  seriousness  of  the  disease,  we 
are  justified,  if  necessary,  in  "curetting"  in  a  cautious  w^ay 
with  a  rather  sharp-eyed  rubber  tube  for  fragments  of  a  sus- 
pected growth  in  the  stomach.  Be  sure  to  blow  out  and  in- 
spect carefully  any  mucus  caught  in  the  eye  of  the  stomach 
tube,  as  tumor  fragments  are  most  apt  to  be  found  in  this. 

If  no  tumor  fragments  are  found  it  is  still  important  to 
examine  the  sediment,  after  centrifuging  or  settling,  for  can- 
cer cells.     The  finding  of  numerous  cells  showing  karyokinesis 


DIAGNOSIS    OF    CARCINOMA    OF    STOMACH  623 

or  irregular  mitosis  is  at  least  very  suspicious,  and  G.  Marini  ^ 
claims  that  carcinoma  can  often  be  diagnosed  from  the  cells  ob- 
tained by  sedimentation. 

The  Boas-Oppler  bacilli  and  their  significance  have  been 
noted  in  the  preceding  lecture.      (See  Fig.  yj?) 

Pus  cells  in  large  numbers  may  be  present  in  the  stomach 
contents  in  a  small  proportion  of  cases  of  gastric  cancer  in  the 
stage  of  ulceration,  but  not  plentifully  in  other  cases,  except 
when  there  is  an  abscess  in,  or  discharging  into,  the  stomach. 
Blood  cells  have  the  same  significance  as  occult  blood.  Cohn- 
heim  considers  the  presence  of  infusoria  suspicious  of  extra- 
ostial  carcinoma.  The  repeated  finding  of  microscopic  food 
remnants  in  the  morning  lavage  water  is  also  considered  sus- 
picious by  some  authors. 

Though  there  is  always  anaemia  in  cancer  of  the  stomach, 
which  increases  as  the  disease  advances,  finally  developing  into 
a  positive  cachexia,  there  are  probably  no  constant  changes  in 
the  blood  that  would  distinguish  it  certainly  from  other  forms 
of  ansemia.  A  disproportionately  low  percentage  of  hemo- 
globin and,  also,  an  absence  of  the  usual  leucocytosis  after  eat- 
ing, have  been  observed,  but  are  by  no  means  present  in  all 
cases,  and,  therefore,  are  not  pathognomonic. 

Too  much  time  should  not  be  lost  over  laboratory  tests ;  yet 
all  proper  diagnostic  means  should  be  employed,  and  a  number 
of  the  more  recent  tests  bid  fair  to  be  of  real  value.  Chief 
among  these,  perhaps,  is  the  use  of  the  x-rays  after  the  ad- 
ministration of  a  bismuth  suspension.  G.  E.  Pfahler  -  con- 
cludes that  the  diagnosis  of  gastric  carcinoma  can  be  made 
earlier  by  means  of  this  aid ;  that  carcinoma  is  demonstrable 
W'hen  it  changes  the  course  of  food  through  the  stomach; 
when  it  decreases  the  volume  of  the  stomach ;  when  it  interferes 
with  peristalsis;  when  it  causes  an  indentation  of  the  outline 
of  the  stomach;  when  it  fixes  or  displaces  the  stomach,  or 
modifies  the  rate  of  evacuation  of  contents.     As  the  examina- 

^Arch.f.  Verdauungskra7ikheiten,  Bd.  xv.,  Hft.  6. 
'^Jour.  Amer.  Med.  Assoc,  Mar.  13,  1909,  p.  853. 


624  THE    GASTRO-INTESTINAL    CLINIC 

tion  is  tedious  and  expensive,  the  case  should  first  be  well 
studied  clinically.  Great  skill  and  caution  are  necessary  in  in- 
terpreting the  findings,  and  all  clinical  data  should  be  at  the 
command  of  the  operator. 

Salomon's  test^  is  made  as  follows:  On  the  previous  day 
the  patient  takes  an  albumin-free  diet,  and  his  stomach  is 
washed  out  in  the  evening.  In  the  morning  the  fasting  stom- 
ach is  washed  with  400  c.c.  of  normal  salt  solution,  introduced 
twice.  This  fluid  is  then  tested  for  nitrogen  by  the  Kjedahl 
method,  and  for  albumin  by  the  Esbach  method.  In  cancer  the 
nitrogen  is  said  to  range  from  10  to  70  mgm.  in  100  c.c,  20  to 
30  mgm.  or  over  being  very  suspicious.  The  albumin  ranges 
from  i-io  to  ^  per  1000  in  carcinoma. 

The  hemolytic  test  has  been  found  positive  in  a  high  per- 
centage of  carcinoma  cases  by  various  observers.  This  con- 
sists in  the  destruction  of  normal  human  red  corpuscles  when 
mixed  with  the  serum  of  the  patient  tested.  As  the  test  is  not 
positive  in  all  cases,  and  is  positive  in  some  other  conditions, 
its  ultimate  diagnostic  value  remains  to  be  determined,  but 
there  is  ground  for  hope  of  definite  aid  from  this  direction. 

Pfeiffer  and  Finsterer  -  claim  that  guinea-pigs  injected  with 
the  serum  of  a  carcinoma  patient,  and  48  hours  later  injected 
with  carcinoma  juice,  show  a  marked  anaphylactic  shock  and 
fall  of  temperature,  these  being  absent  in  untreated  pigs  or 
those  injected  with  normal  serum.  The  discovery  of  this 
anaphylactic  property  in  a  patient  with  a  tumor  is  said  to  con- 
firm the  diagnosis  of  carcinoma.  If  it  disappears  after  opera- 
tion, the  cure  may  be  considered  definite ;  its  reappearance  is  a 
signal  for  fresh  intervention. 

Neubauer  and  Fischer  ^  report  the  finding  in  the  stomach 
contents  of  patients  with  gastric  carcinoma  of  a  ferment  pro- 
duced by  the  carcinoma  which  is  capable  of  splitting  polypep- 
tids.  For  practical  tests  they  used  the  artificial  polypcptid 
glycyltryptophan,  which  yields  tryptophan  on  hydrolysis.    The 

^  Jcntrnal  A.  M.  A.,  Sept.  12,  1903,  p.  694. 
2  IVtener  klin.  Wochenschrift,  July  15,  1909. 
^Deutsche  Arch./,  klin.  Med.,  1909,  xcvii.  p.  499. 


DIAGNOSIS    OF    CARCINOMA    OF    STOMACH  625 

technic  is  not  difficult,  and  their  results  were  positive  in  a  high 
percentage  of  cases,  but  whether  the  test  will  be  of  real  value 
in  making  an  early  diagnosis  remains  to  be  demonstrated. 

Ascoli  and  his  pupil  Izar  ^  have  recently  sought  to  apply  their 
"  meiostagmin  "  reaction  to  the  diagnosis  of  malignant  neo- 
plasms. This  reaction  consists  in  the  definite  lowering  of  sur- 
face tension  (measured  by  the  stalagmometer  of  J.  Traube)  of 


Fig.  80. — Section  from  carcinoma  of  the  pylorus. 


an  immune  serum  when  mixed  with  its  specific  antigen  and  in- 
cubated for  two  hours  at  37°  C.  The  patients  examined  in- 
cluded sixty-two  suffering  with  malignant  growths,  carcinomas 
or  sarcomas.  Of  these  fifty-eight  gave  a  positive  meiostagmin 
reaction.  Forty-eight  patients  suffering  with  various  other 
diseases  all  gave  a  negative  reaction.  These  results  are  most 
promising,  but,  as  in  the  case  of  some  of  the  preceding  tests, 
the  practical  value  of  the  method  remains  to  be  demonstrated. 
'^  Miinchen  Med.  Wochenschrift,  1910,  Ivii,  182. 


626  THE    GASTRO-INTESTINAL    CLINIC 

Boas  considers  cedema  of  the  ankles  or  feet,  even  though  only 
transitory,  a  sign  of  cancer  of  the  stomach — and  one  which 
may  be  present  in  the  beginning  of  the  disease. 

In  cancer  of  the  cardia,  besides  the  symptoms  previously 
mentioned,  pain  is  Hkely  to  be  ehcited  by  pressure  or  percussion 
over  the  lower  end  of  the  sternum,  and  the  stomach  will  be  ul- 
timately contracted,  rather  than  dilated  as  when  the  pylorus  is 
involved.  In  cancer  of  the  body  of  the  stomach,  the  organ 
may  be  either  of  normal  size  or  contracted,  rarely  enlarged, 
unless  the  enlargement  antedated  the  tumor,  and  there  is  more 
likelihood  of  the  disease  running  a  latent  course  here  than  in 
other  parts  of  the  organ.  Not  seldom  it  is  unsuspected  until  a 
tumor  is  palpable. 

The  diagnosis  of  cancer  from  ulcer,  from  hyperchlorhydria 
and  acid  gastric  catarrh,  as  well  as  from  gastralgia,  is  fully 
given  in  a  tabular  statement  which  will  be  found  in  Lecture 
LIIL,  on  the  Diagnosis  of  Gastric  Ulcer.  It  is  also  further 
discussed  in  Lecture  LXL,  entitled  the  Differential  Diagnosis 
between  Gastric  Carcinoma  and  Round  Ulcer. 

Carcinomatous  Ulcer. — Carcinoma  which  has  developed  in 
an  ulcer  can  be  differentiated  from  simple  ulcer  by  the  history, 
there  having  been  at  first  the  usual  symptoms  of  ulcer,  followed 
by  cachexia  with  loss  of  strength  and  flesh,  and  a  change  in 
the  character  of  the  pain,  from  one  that  was  acute,  paroxysmal, 
and  much  aggravated  by  food,  to  a  dull  or  moderate  pain  that 
is  more  or  less  constant  with  no,  or  only  an  unimportant,  in- 
crease after  eating.  Later  the  presence  of  a  movable,  uneven 
tumor  would  clinch  the  diagnosis.  The  persistence  of  free 
HCl  with  the  symptoms  and  signs  of  cancer  usually  means  a 
carcinomatous  ulcer. 

From  chronic  asthenic  gastritis  cancer  of  the  stomach  cannot 
at  first  be  positively  diagnosticated,  since  more  or  less  catarrh 
accompanies  cancer.  In  both,  much  mucus,  a  heavily  furred 
tongue,  and  nausea  may  occur ;  and  in  both  there  is  usually 
sensitiveness  to  pressure  over  the  organ;  but  chronic  catarrh 
of  the  stomach  is  rarely  painful,  especially  in  its  earlier  stages, 


DIAGNOSIS    OF    CARCINOMA    OF    STOMACH  627 

while  cancer  may  be  almost  from  the  start.  When  there  is 
pain  with  gastritis,  it  is  nearly  always  digestive,  /.  e.,  confined 
to  the  period  of  two  to  six  hours  following  meals  when  diges- 
tion is  in  progress;  while  in  cancer,  though  the  pain  may  be 
aggravated  somewhat  after,  eating,  there  is  likely  to  be,  at  least, 
an  uncomfortable  sensation,  even  when  the  viscus  is  empty. 
Besides,  in  the  later  stages  of  cancer,  changed  blood  nearly  al- 
ways appears  from  time  to  time,  both  in  the  vomit  and  stools, 
but  anything  of  the  kind  rarely  occurs  in  gastric  catarrh. 

Apart  from  the  pain,  hemorrhages,  and  tumor  of  cancer, 
the  most  striking  difference  is,  that  in  catarrh,  the  symp- 
toms will  nearly  always  steadily  improve  under  a  proper  treat- 
ment, strictly  and  persistently  carried  out,  while  cancer,  with 
the  exception  of  possible  brief  spells  of  relief,  or  even  gain  in 
appetite  and  digestive  power,  tends  to  grow  surely  worse  in 
spite  of  any  treatment.  Besides  the  motor  power  of  the  stom- 
ach walls,  which  is  so  constantly  and  usually  markedly  lowered 
in  cancer,  is  often  good  or  fair  during  a  large  part,  at  least,  of 
the  course  of  chronic  gastritis,  and  may  be  quite  normal  for 
years.  Finally,  the  appetite,  color,  flesh,  and  strength,  which 
are  not  necessarily  much  impaired  in  gastric  catarrh  of  moder- 
ate degree  and  are  often  well  maintained,  are  always  progress- 
ively lost  in  carcinoma  from  a  comparatively  early  stage,  as  a 
rule,  with  possible  slight  exceptions  for  a  week  or  two. 

From  atrophy  of  the  stomach,  which  is  the  final  stage  of 
chronic  gastric  catarrh,  it  is  also  difficult  sometimes  to  diag- 
nosticate cancer,  since  there  may  be  a  complete  absence  of  free 
HCl  and  of  the  ferments  in  both,  and  exceptionally  there  may 
be  much  pain  in  atrophy.  But  the  pain  of  atrophy  is  digestive, 
and  in  my  experience  exceptional,  and  the  tongue  is  likely  to  be 
rather  clean,  and  the  wash  water  after  lavage  free  from 
mucus,  while  in  cancer  the  pain  is  more  constant,  the  tongue 
always  dirty,  and  the  stomach  generally  full  of  mucus. 

The  nervous  forms  of  lowered  digestive  ability  should  never 
be  confounded  with  cancer,  since  they  are  generally  improved 
by  tonic  treatment  and  generous  feeding,  and  are  very  change- 


628  THE    GASTRO-INTESTINAL    CLINIC 

able  as  to  both  the  secretion  of  HCl  and  all  the  symptoms,  in- 
stead of  showing  an  almost  continuous  and  rapid  downward 
course,  as  does  cancer.  Pain  is  not  very  often  present  in  them 
— never  constant  pain — and  hemorrhage  is  wanting. 

Dilatation  of  the  stomach,  dependent  upon  a  spasmodic 
contraction  of  the  pylorus,  an  actual  narrowing  of  the  outlet, 
as  the  result  of  a  healed  ulcer,  or  obstruction  from  other 
mechanical  cause  not  malignant,  needs  to  be  differentiated  from 
pyloric  cancer,  since  in  the  former  there  may  be,  though  ex- 
ceptionally, marked  anaemia,  and  there  is  often  severe  pain, 
though  paroxysmal  in  character,  as  well  as,  generally,  the 
form  of  vomiting  characteristic  of  stagnation  and  retention  of 
food.  But  in  benign  obstruction  HCl  is  usually  present  in 
normal  or  excessive  proportion,  and  the  ferments  also ;  conse- 
quently meat  fibers  and  other  albumins  are  usually  digested, 
and  mucus  is  not  abundant.  Sarcinse  are  commonly  present  in 
great  numbers,  as  well  as  yeast-colonies,  though  the  latter  may 
also  be  abundant  in  cancer.  Then,  there  is  not  often  so  bad 
a  tongue,  nor  so  persistent  a  failure  of  the  appetite  with  an 
especial  disgust  for  meats  in  the  dilatation  from  other  causes, 
as  in  that  from  malignant  disease  of  the  pylorus.  The  stenos- 
ing  form  of  gastritis  also  produces  a  dilatation  with  symptoms 
very  similar  to  those  resulting  from  other  non-malignant  forms 
of  pyloric  stenosis. 

For  the  recognition  of  a  cancerous  tumor  of  the  stomach,  in- 
spection, percussion,  and  palpation  may  all  help  somewhat, 
but  the  last  will  yield  by  far  the  most  information  to  the  physi- 
cian with  skilled  fingers.  You  should  examine  the  patient  by 
all  these  methods  in  various  positions  of  the  body — lying  su- 
pine and  prone,  and  on  either  side,  as  well  as  standing — ^both 
before  and  after  inflation  of  his  stomach  with  gas,  as  well  as 
before  and  after  letting  him  drink  a  pint  of  water.  Inflation 
with  gas  is  often  particularly  useful  in  bringing  hidden  tu- 
mors into  view.  In  the  case  of  tumors  of  the  anterior  wall, 
transillumination  by  means  of  the  Einhorn  electric  lamp,  intro- 
duced into  the  stomach  after  the  patient  has  drunk  one  or  two 


DIAGNOSIS    OF    CARCINOMA    OF    STOMACH 


629 


glasses  of  water  will  sometimes  help  in  the  diagnosis.    But  the 
Roentgen  rays  will  often  afford  more  positive  information. 

The  Differential  Diagnosis  of  Gastric  Cancer  from  Other 
Abdominal  Tumors. — The  annexed  table,  taken  from  Boas' 
"  Diagnostic  und  Therapie  der  Magenkrankheiten,"  cannot 
well  be  improved  upon.  The  stomach  is  first  to  be  inflated 
with  air,  or  with  carbonic  acid  gas ;  afterward  the  colon  is 
filled  with  warm  water  by  a  fountain  syringe.  The  results 
upon  tumors  in  different  locations  are  recorded  in  the  table  as 
follows : 


Turners  of  the 


I.  Stomach, 
{a)  pylorus, 

(fi)  anterior 
wall  and 
g  r  e  ater 
curvature 

(c)  the  lesser 
curvature 


2.  Liver, 


3.  Spleen, 


4.  Colon, 

5.  Kidneys, 


6.  Omentum, 

7.  Pancreas, 


Up07t  Inflation  of  the 
Stomach, 


Upon  Filling  the  Colon 
with    Water, 


Move   to  the  right  and 
downward. 


Feel  broader  and  less  dis- 
tinct at  their  margins. 

Disappear  entirely. 


Move  upward  and  to  the 
right,  so  that  the  anterior 
border  of  the  organ  becomes 
more  distinctly  palpable. 


Move  towards   the  left ; 
often  also  downward. 


Move  upward. 


Move  downward. 

Disappear  upon  inflation 
of  the  stomach. 


All  tumors  of  the  stomach 
simply  move  upward. 


Raise  the  lower  border 
upward  ;  a  tumor  of  the  gall 
bladder  is  drawn  forward. 
With  very  large  tumors 
there  may  be  no  change  of 
position. 

Move  upward  and  to  the 
left.  Movable  tumors  may 
thus  become  recognizable  in 
the  normal  splenic  region. 

Do  not  move  upward.  At 
first  they  may  ascend  a  little, 
but  finally  disappear.  Mov- 
able kidneys  return  to  the 
proper  renal  region.  In 
large  tumors  of  the  kidneys 
the  median  border  only  be- 
comes indistinct. 

Move  downward. 


LECTURE  LXI 

THE  DIFFERENTIAL  DIAGNOSIS  BE- 
TWEEN GASTRIC  CARCINOMA  AND 
ROUND    ULCER 

The  diagnosis  of  carcinoma  of  the  stomach  has  already  been 
quite  fully  discussed,  and  in  the  lecture  on  The  Diagnosis  of 
Gastric  Ulcer  a  table  is  included,  in  which  are  given  in  a  con- 
densed form  the  chief  distinguishing  characteristics  between 
that  disease  and  others  with  similar  symptoms,  including  gas- 
tric cancer.  But  the  differential  diagnosis  between  these  two 
may  with  advantage  be  further  amplified  and  emphasized. 

For  the  expert  gastrologist  it  is,  as  a  rule,  easy  enough  to  di- 
agnosticate a  carcinomatous  growth  in  the  region  of  the  stom- 
ach from  a  gastric  ulcer.  When  a  tumor  can  be  felt  in  a  posi- 
tion, or  of  a  size  or  form,  which  would  exclude  the  elongated 
cylindric  thickening  of  the  pylorus  due  to  an  ulcer  in  that  re- 
gion, cancer  must  always  be  suspected,  and  may  be  diagnosti- 
cated positively  if  tliere  are  present  also  the  symptoms  of  the 
latter  disease — viz.,  a  progressive  loss  of  flesh  and  strength, 
pain,  vomiting,  hematemesis,  cachexia,  and  an  absent  or 
markedly  lowered  secretion  of  the  HCl  and  ferments  of  the 
gastric  juice.  Indeed,  when  such  a  tumor  can  be  made  out,  and 
a  part  only  of  the  above  symptoms  are  present,  including  pain, 
emaciation,  and  a  rapid  loss  of  strength,  or  even  the  latter  two 
without  pain,  you  may  be  sure  enough  of  cancer  to  advise  an 
exploratory  incision,  provided  there  be  no  signs  of  metastases 
or  involvement  of  neighboring  glands. 

But  it  is  in  the  beginning  of  the  disease  before  a  tumor  is 
demonstrable  that  it  is  very  difficult  to  recognize.  The  early 
stages  of  carcinoma  involving  the  body  of  the  stomach  or  the 

630 


GASTRIC    CARCINOMA    AND    ROUND    ULCER  63 1 

pylorus  are  more  likely  to  be  confounded  with  gastric  ulcer 
than  any  other  disease,  especially  by  physicians  who  do  not 
make  a  practice  of  testing,  or  having  tested,  the  stomach  con- 
tents in  every  suspicious  or  stubborn  case  of  indigestion. 
Moreover,  an  analysis  of  the  gastric  contents  with  the  finding 
of  HCl  in  moderate  excess,  though  it  affords  strong  presump- 
tive evidence  that  such  symptoms  as  pain  in  the  stomach,  with 
occasional  vomiting,  with  or  without  hemorrhage,  are  due  to 
ulcer,  does  not  exclude  the  possibility  of  cancer  which  has  de- 
veloped in  the  site  of  a  previous  ulcer ;  and,  still  less,  on  the 
other  hand,  would  the  failure  of  HCl  alone  prove  certainly  the 
existence  of  cancer.  The  totality  of  the  chemic  and  micro- 
scopic findings  and  the  symptoms,  as  well  as  the  results  of 
treatment,  must  decide  in  the  absence  of  a  palpable  tumor. 

Cancer  of  the  Cardia,  Differentiated  from  Ulcer, — You  are 
not  likely  to  mistake  cancer  of  the  cardiac  orifice  of  the  stom- 
ach for  ulcer,  since  the  symptoms  of  these  two  affections  are 
widely  different.  In  the  former,  the  pain  and  sensitiveness  to 
pressure  are  both  usually  experienced  over  the  lower  end  of 
the  sternum,  rather  than  over  the  stomach  itself,  and  careful 
sounding  will  discover  an  obstruction  at  the  cardiac  opening. 
There  is  difffculty  in  swallowing,  and  finally  regurgitation 
from  the  esophagus  of  wholly  undigested  food,  not  true  vom- 
iting. 

In  the  other  forms  of  gastric  carcinoma,  the  main  points  in 
which  the  symptoms  differ  from  those  of  ulcer  are  the  tend- 
ency of  the  pain  to  persist  during  most  of  the  twenty-four 
hours,  without  regard  to  the  digestive  process,  whereas,  in 
ulcer,  there  is  usually  an  entire  absence  of  pain  until  food  is 
taken,  when  it  shortly  comes  on  more  or  less  acutely  and  per- 
sists until  the  meal  has  been  completely  digested — often  until 
it  has  been  evacuated  from  the  stomach.  After  its  evacuation, 
there  is  generally  an  entire  cessation  of  the  pain  from  ulcer. 
As  to  hemorrhage,  there  may  be  none  at  all  in  either  disease 
until  it  is  considerably  advanced.  The  most  important  differ- 
ences are    that  in  cancer  there  are  likely  to  be  frecjuently  re- 


632  THE    GASTRO-INTESTINAL    CLINIC 

curring  small  bleedings  after  ulceration  of  the  growth  has 
begun,  but  rarely  a  large  or  serious  one.  In  ulcer,  while  the 
bleedings  may  be  either  large  or  small,  there  are  apt  to  be  spells 
of  hemorrhage  at  long  intervals,  and  generally  they  are  larger 
and  involve  a  greater  loss  of  blood  than  in  the  case  of  cancer. 
During  such  a  spell,  the  loss  of  blood  may  be  temporarily  con- 
trolled by  remedies,  but  will  often  recur  within  a  day  or  two, 
and  such  recurrences  may  continue  until  the  ulcer  can  be 
healed,  or  till  a  clot  becomes  organized  in  the  bleeding  vessel. 
Then  there  may  be  no  more  for  weeks  or  months,  even  though 
the  ulcer  persists  with  its  other  symptoms,  pain,  tenderness  on 
pressure,  etc.,  except,  of  course,  when  treatment  has  been  so 
thorough  and  effective  as  to  produce  entire  healing. 

Chief  Diagnostic  Points. — Bear  in  mind  that  in  cancer  there 
is  a  progressive  loss  of  appetite,  Hesh,  strength,  and  color,  al- 
most from  the  beginning,  while  in  ulcer  there  is  most  commonly 
a  sharp  appetite  with  other  indications  of  a  good  nutrition,  ex- 
cept when  the  ulcer  is  very  chronic,  or  has  developed  after  such 
a  long  persistence  of  a  neglected  and  marked  hyperchlorhyd- 
ria  as  to  have  seriously  impaired  the  health.  The  pain,  as 
well  as  the  hemorrhage  in  ulcer,  is  likely  to  be  more  severe  than 
in  cancer.  It  needs  to  be  repeated  also,  that  the  pain  in  ulcer  is, 
almost  without  exception,  limited  to  the  time  when  the  stomach 
contains  food;  and  the  more  irritating  the  form  of  the  food, 
the  greater  the  pain,  whereas,  in  cancer,  though  there  may  be 
somewhat  more  pain  during  digestion,  it  is  the  rule  that  a  dull, 
gnawing  ache  persists  pretty  constantly,  particularly  in  pyloric 
cancer,  so  that  sleep  is  generally  prevented,  except  with  some 
help  from  anodynes.  Sleep  is  also  often  impaired  in  ulcer,  as 
well  as  in  excessive  HCl  secretion  merely,  but  not  usually  from 
pain,  unless  hearty  meals  are  taken  at  night. 

In  both  cancer  and  ulcer,  there  may  be  vomiting  of  changed 
blood  resembling  coffee-grounds,  instead  of  fresh  blood,  but 
this  is  rather  more  frequent  in  cancer.  Altered  blood  or 
occult  blood  may  also  be  mixed  with  the  feces  in  either 
disease,   even   when   there   has  been   no   recent  hematemesis. 


GASTRIC    CARCINOMA    AND    ROUND    ULCER  633 

This  results  usually  when  there  has  been  too  small  a  bleeding  to 
provoke  emesis,  and,  in  the  absence  of  hematemesis,  points 
rather  to  cancer  than  to  ulcer. 

Tenderness  on  pressure  in  or  near  the  median  line,  just  below 
the  lower  end  of  the  sternum,  as  well  as  to  either  side  of  the 
spine  at  the  level  of  the  two  lowest  ribs^  is  often  demonstrable 
in  ulcer,  but  much  less  frecjuently  in  carcinoma  of  the  stomach. 
It  is  not  rarely  present,  however,  in  other  diseases,  as  in  neu- 
rasthenia. Yet  when  such  tenderness  is  very  acute  and  marked, 
especially  posteriorly,  you  should  think,  first  of  all,  of  ulcer. 

It  is  noteworthy,  however,  that  many  of  the  diagnostic 
symptoms,  above  mentioned,  may  be  wanting  particularly  in 
the  earliest  stages  of  the  twO'  diseases.  The  most  help  may 
then  be  obtained  from  the  chemic  and  microscopic  examina- 
tion of  the  stomach  contents,  and  the  microscopic  examina- 
tion of  particles  accidentally  or  purposely  scraped  off  from  the 
gastric  mucous  membrane.  The  finding  of  a  normal,  or  es- 
pecially of  an  excessive,  percentage  of  HCl  would  speak  in 
favor  of  ulcer,  while  a  very  low  percentage,  or  absence,  of  HCl 
would  render  the  diagnosis  of  cancer  decidedly  more  probable. 
The  presence  of  a  considerable  percentage — one  part  in  a 
thousand  or  more — of  lactic  acid  would  still  further  increase 
such  a  probability,  as  would  also  the  finding  of  the  Boas- 
Oppler  bacilli,  or  the  histologic  changes  characteristic  of  car- 
cinoma. 

Carcinomatous  ulcer  is  that  form  of  gastric  ulcer  in  which 
cancerous  degeneration  has  taken  place,  and  the  disease  thence- 
forth behaves  like  cancer.  It  does  not  differ  materially  from 
other  forms  of  carcinoma  of  the  stomach,  either  as  to  its  signs 
or  symptoms,  except  that  a  normal  or  excessive  percentage  of 
HCl  usually  persists  in  such  cases,  thus  tending  to  mislead  the 
physician  who  bases  his  diagnosis  too  exclusively  upon  the  re- 
sults of  a  chemic  analysis  of  the  gastric  contents.  You  should 
suspect  the  presence  of  carcinomatous  ulcer  whenever  you  find 
the  symptoms  and  cachexia  of  cancer  to  have  gradually  de- 
veloped in  a  case  with  a  history  of  gastric  pain  and  hemorrhage 


634  THE    GASTRO-INTESTINAL    CLINIC 

running  back  over  a  long  period,  especially  when  the  disease  has 
lasted  more  than  two  years.  Primary  gastric  carcinoma  most 
fi^quently  comes  on  suddenly  in  persons  who  have  previously 
had  a  good  digestion. 

The  Therapeutic  Test. — In  doubtful  early  cases,  the  diag- 
nosis may  often  be  made  by  the  therapeutic  test.  For  ex- 
ample, if  you  should  have  a  patient  complaining  of  pain  in  the 
gastric  region,  directly  after  meals,  but  to  a  slight  extent  also 
at  other  times,  with  occasional  vomitings,  beginning  loss  of 
flesh  and  strength  without  much  change  of  color,  and  no  tumor 
to  be  felt,  you  might  well  be  in  doubt  as  to  what  form  of  dis- 
ease existed.  The  fact  that  the  pain  persisted  to  some  extent 
after  the  stomach  was  empty,  would  look  much  more  like  car- 
cinoma than  either  ulcer,  hyperchlorhydria,  or  gastritis.  Still, 
it  w'ould  not  exclude  the  possibility  of  a  gastralgia  of  nervous 
origin,  and  the  pain  between  meals  might  be  due  to  fermenting 
portions  of  undigested  food  in  the  small  intestine,  or  to  large 
amounts  of  gas,  with  marked  distention  of  the  stomach.  On 
the  other  hand,  there  might  be  a  similar  case  in  which  pain  was 
experienced  only  when  the  stomach  contained  food,  which 
would,  of  course,  suggest  the  probability  of  ulcer  or  gastritis, 
rather  than  cancer.  And  yet,  in  the  early  stages  of  cancer,  es- 
pecially when  the  body  of  the  stomach,  and  not  the  pylorus,  is 
involved,  the  pain  may  be  only  complained  of  during  the  di- 
gestive act,  and  sometimes  not  even  then.  In  all  such  doubtful 
cases  the  diagnosis  can  be  pretty  certainly  determined  by  put- 
ting the  patient  to  bed  and  feeding  by  the  rectum,  together  with 
the  other  curative  measures  advised  for  ulcer.  In  any  recent 
case  of  ulcer,  rest  in  bed,  with  rectal  feeding,  and  30-  to  60- 
grain  doses  of  bismuth  subnitrate,  three  or  four  times  a  day, 
with  sometimes  large  doses  of  an  alkali  to  neutralize  the  ex- 
cessive HCl,  will  almost  certainly  remove  the  prominent  symp- 
toms within  a  few  days,  and  if  persisted  in  for  a  w^ek  or  two, 
followed  by  a  longer  continuance  of  the  bismuth,  with  a  liquid 
diet  by  the  mouth,  gradually  increased,  will  insure  usually  a 
speedy  and  complete  cure  of  the  disease.     Marked  relief,  too, 


GASTRIC    CARCINOMA    AND    ROUND    ULCER  635 

would  likely  follow  if  the  cause  of  the  symptoms  were  chronic 
gastritis,  although  not  so  certainly  then,  since  lavage  would 
often  need  to  be  added  to  the  treatment.  But  in  a  case  of 
cancer,  while  certain  of  the  symptoms  might  be  favorably  in- 
fluenced at  first,  the  growth  would  usually  progress  in  spite  of 
all  treatment,  and  after  a  week  or  two  of  possible  slight  ameli- 
oration, the  symptoms  would  recur  and  become  increasingly 
troublesome.  This  is  a  valuable  method  when  patients  can  be 
sufficiently  controlled  to  carry  it  out,  and  when  there  is  even  a 
possibility  of  so  grave  an  organic  disease  as  carcinoma  of  the 
stomach,  it  is  vitally  important  to  exhaust  every  means  to  ar- 
rive at  the  diagnosis  at  the  earliest  possible  moment,  in  order 
that  the  surgeon  may  be  summoned  in  time  to  afford  the  pa- 
tient the  only  chance  of  recovery. 

Many  observers  have  lately  testified  to  the  great  value  of 
the  more  delicate  tests  for  minute  traces  of  blood  in  the  stomach 
contents  and  feces  in  the  diagnosis  of  gastric  ulcer  and  cancer. 
See  Lecture  LVIII. 


LECTURE  LXII 

THE  TREATMENT  OF  CARCINOMA  AND 
OTHER  TUMORS  OF  THE  STOMACH 

The  prognosis  of  gastric  cancer  has,  until  quite  recently, 
been  considered  absolutely  hopeless.  However,  since  the  sur- 
gery of  the  abdomen  has  been  so  extraordinarily  perfected,  oc- 
casional cases  of  apparent  cure  by  early  operative  intervention 
have  been  reported.  Then,  too,  the  achievements  of  the 
Roentgen  rays,  violet  rays,  the  Finsen  light,  and  radium,  in 
ameliorating,  and  apparently,  in  some  isolated  cases,  even  cur- 
ing malignant  growths  in  various  other  parts  of  the  body, 
naturally  awakened  the  hope  that  cancer  of  the  stomach,  and 
of  the  other  abdominal  viscera,  would  ultimately  yield  to  some 
of  these  mysterious  agents,  but  after  some  years  of  thorough 
trial  this  hope  is  yet  to  be  justified.  More  encouraging,  per- 
haps, are  the  results  being  obtained  by  the  many  investigators 
into  the  nature  and  cause  of  carcinoma,  and  one  need  not  be 
branded  as  visionary  who  looks  forward  to  the  discovery  of  a 
curative  serum. 

Treatment  with  X-Rays,  etc. — The  results  of  the  trial  of 
x-rays  in  this  region  hitherto  have  been  much  less  encouraging 
than  elsewhere  in  the  body.  Caldwell  ^  cites  one  case  reported 
by  Despeignes  -  in  which  carcinoma  of  the  stomach  improved 
under  daily  applications  of  the  x-rays,  and  quotes  Skinner  ^  as 
having  treated  five  cases  of  intra-abdominal  tumors,  with 
the  result  that  two  of  them  became  smaller,  and  in  two  of  the 
others  there  was  gain  in  the  constitutional  condition. 

1  "The  Roentgen  Rays  in  Therapeutics  and  Diagnosis,"  by  W.  A.  Pusey 
and  Eugene  W.  Caldwell,  Saunders  &  Co.,  Philadelphia,  1903. 
"^  Semaine  Mid.,  1896,  xvi.  p.  cxlvi. 
^  Rev.  Int.  d' Electrothirapic ,  1902,  xii.  p.  28. 

636 


TREATMENT   OF    CARCINOMA  AND   OTHER   TUAIORS        637 

Dr.  Wm.  B.  Coley  wrote  the  author  in  1894  as  follows:  "  I 
belie\'e  that  the  x-ray  gives  the  greatest  promise  when  used  as 
a  prophylactic,  after  primary  operation,  although,  even  here, 
the  data  are  insufficient  and  contradictory." 

Dr.  W.  B.  Snow,  a  prominent  authority  in  electro-thera- 
peutics, reported  a  case  of  pyloric  cancer  in  the  Journal  of  Ad- 
vanced Therapeutics,  of  June,  1902,  in  which,  though  the  dis- 
ease was  far  advanced,  and  the  patient  in  a  critical  condition 
when  the  treatment  was  instituted,  six  x-ray  applications  pro- 
duced remarkably  favorable  results,  including  a  cessation  of 
severe  hematemesis  as  well  as  all  nausea,  vomiting,  hiccough, 
and  dyspnoea,  an  improvement  in  the  pulse,  and  especially  a 
decided  softening  of  the  tumor  itself.  Later,  the  patient  be- 
came suddenly  worse  and  died  with  symptoms  pointing  to  gen- 
eral auto-infection.  This  is  one  of  the  dangers  attendant  upon 
the  rapid  resolution  of  an  internal  malignant  growth  by  means 
of  the  x-rays. 

So  much  has  already  been  done  with  these  new  agents  that 
we  are  justified  in  hoping  for  still  more.  The  most  recent 
reports,  from  entirely  trustworthy  sources,  leave  little  room 
for  question  that  some  of  these  forces  are  now  causing  the 
disappearance — a  gradual  melting  away,  as  it  were — of  a  cer- 
tain proportion  of  cancers  and  sarcomas  on  the  exterior  parts 
of  the  body,  as  well  as  in  the  more  accessible  cavities.  It  has 
not  been  proved  that  these  are  definite  cures,  but  the  results 
are  nevertheless  encouraging. 

Two  difficulties  are  in  the  way  of  the  achievement  of  like  re- 
sults in  the  stomach  and  intestines:  ( i)  The  depth  of  the 
overlying  tissues  which  the  rays  must  penetrate  before  they  can 
effectively  influence  the  diseased  structures,  and  (2)  the  ina- 
bility, under  present  conditions  of  the  operator,  to  see  how  to 
apply  the  rays  in  just  the  right  position,  and  at  the  proper  dis- 
tance from  the  point  to  be  affected.  Neither  of  these,  how- 
e\'er,  would  seem  to  be  insuperable. 

Carl  Beck  ^  of  New  York  has  recently  reported  cases  of 
^  N.  V.  Med.  Jour.,  Mar.  27,  1909. 


638  THE    GASTRO-INTESTINAL    CLINIC 

pyloric  and  other  abdominal  cancers  in  which  he  made  an 
>  incision  and  stitched  the  growth  to  the  abdominal  wall,  after- 
ward applying  the  x-rays.  In  some  cases  the  results  were  ap- 
parently favorable. 

Storck  of  New  Orleans  reports  ^  a  case  of  undoubted  carci- 
noma of  the  stomach  which  was  greatly  relieved  after  a  few 
treatments  with  radium.  He  applied  it  by  means  of  a  con- 
trivance of  his  own  invention  and  called  by  him  an  intragas- 
tric radiode.     He  thus  describes  it: 

"  It  consists  of  an  aluminum  capsule  containing  10  mg.  of 
7000  radioactive  radium  attached  to  a  flexible  copper  wire 
passed  through  a  suitable  rubber  tube  (a  stomach  tube  will 
answer  every  purpose),  the  capsule  being  allowed  to  project 
beyond  the  end  of  the  tube.  The  intragastric  radiode  is  so 
manipulated  as  to  come  immediately,  or  as  nearly  as  possible, 
in  contact  with  the  growth." 

Einhorn  in  his  textbook  on  gastric  diseases  describes  his 
methods.  The  radium  receptacle,  of  glass,  is  enclosed  in  a 
hard-rubber  capsule;  to  this  a  silk  thread  is  attached,  long 
enough  to  reach  to  the  patient's  ear  or  shirt  when  the  capsule 
is  in  the  stomach.  The  capsule  is  swallowed  and  allowed  to 
remain  in  the  stomach  from  one-half  to  one  hour.  In  cardiac 
and  esophageal  cancers  he  uses  a  similar  capsule,  but  this  is 
attached  to  a  soft  rubber  tube  containing  a  mandrin  to  facil- 
itate introduction.  The  mandrin  is  removed  after  the  in- 
troduction, and  the  capsule  is  left  in  contact  with  the  tumor 
for  one-half  to  one  hour.  In  the  latter  class  of  cases  Einhorn 
reports  definite  and  marked  alleviation  of  symptoms- — in- 
creased permeability  of  the  stricture,  etc. ;  but  in  the  gastric 
carcinomas  proper  the  results  were  much  less  encouraging. 

Even  the  slightly  encouraging  results  so  far  obtained  from 
the  experience  with  x-rays  in  malignant  growths  of  the  ab- 
dominal viscera  are  enough  to  warrant  a  trial  of  them  in  in- 
operable cases,  and  especially  after  an  operation  for  the  re- 
moval of  the  tumor  has  been  done,  so  as  to  accomplish  as  much 
^  Am.  Med.,  May  21,  1904. 


TREATMENT   OF   CARCINOMA   AND  OTHER   TUMORS        639 

as  possible  in  this  way  toward  the  prevention  of  a  recurrence. 
We  should  stop  at  nothing  that  promises  in  howsoever  small 
a  degree  to  lessen  the  danger  of  recurrence,  and  even  though 
it  should  recjuire  hundreds  of  treatments,  and  involve  severe 
burnings  of  the  skin,  these  would  be  gladly  undergone  by  many 
patients  if  thereby  they  could  be  encouraged  to  hope  that  the 
tumor  would  not  recur,  or  even  that  it  would  only  recur  after 
a  respite  of  some  years. 

The  arguments  advanced  in  favor  of  following  every  opera- 
tion for  the  removal  of  cancer  with  a  prolonged  treatment  by 
the  x-rays  seem  to  be  strong,  and  there  are  also  equally 
strong  reasons  for  beginning  the  treatment  of  the  same  with 
this  agent  whenever,  from  any  cause,  the  operation  has  to  be 
deferred,  though  it  be  for  even  a  few  days  only.  If  the  x-rays 
could  save  only  one  case  in  a  hundred,  or  only  prolong  by  a  few 
months  the  lives  of  such  patients  in  a  small  proportion  of  cases, 
it  should  be  employed,  since,  whatever  its  inconveniences,  it 
can  scarcely  add  to  the  dangers  of  a  fatal  termination,  but,  to 
some  extent  at  least,  lessens  them. 

Later  Reports  Concerning  the  X-Ray,  Radium,  etc.,  in 
Cancer. — The  foregoing  reports,  conclusions,  and  comments 
concerning  these  newer  therapeutic  forces  were  mainly  written 
in  the  years  1903  and  1904,  before  the  appearance  of  the  first 
edition  of  this  work.  Since  then  there  have  been  waves  of 
pessimism  and  optimism  as  to  their  value.  Meanwhile  the 
x-ray  specialists  have  m.ostly  continued  to  claim  good  results 
in  many  cases  of  external  cancer  and  in  those  involving  the 
cavities  easily  accessible  from  without — the  rectum,  vagina, 
mouth,  naso-pharynx,  etc. — though  there  has  been  little  re- 
liable evidence  pointing  to  permanent  cures  even  in  such  cases. 
It  has  been  generally  conceded  that  in  the  more  deep-seated 
malignant  tumors,  as  in  the  stomach  and  intestines,  nothing  was 
to  be  expected  even  in  the  way  of  palliation  or  temporary  sub- 
jective improvement  except  from  the  knife,  and  then  only  in 
case  the  exceedingly  difficult  and  mostly  impossible  task  of 
making  a  very  early  diagnosis — even  before  the  finding  of  a 


640  THE    GASTRO-IXTESTIXAL    CLIXIC 

tumor — could  be  accomplished.  However,  some  compara- 
tively recent  reports  are  somewhat  encouraging  again.  In 
^Germany  the  Institute  for  Cancer  Research  in  Heidelberg,  un- 
der the  direction  of  Prof.  Dr.  V.  Czerny,  has  been  furnished 
with  liberal  amounts  of  some  highly  concentrated  preparations 
of  radium  for  experimental  purposes,  including  a  radium 
powder  said  to  be  so  powerful  that  it  can  exert  a  force  of 
99,000  volts  for  each  125  grams  of  the  drug  per  hour,  a  strong 
radium  salve  and  a  solution  of  the  remedy  which  can  be  ef- 
fectively employed  both  by  applying  compresses  soaked  with 
it  for  six  to  eight  hours  at  a  time,  and  by  having  the  patient 
drink  it  freely  for  malignant  tumors  in  the  stomach  or  esoph- 
agus. By  pushing  the  drug  boldly,  which  has  been  found 
safe,  often  by  the  combined  use  of  several  of  these  methods, 
and  at  the  same  time  employing  when  practicable  the  x-rays 
and  all  the  other  approved  remedies.  Dr.  A.  Caan  reports  from 
this  Cancer  Research  Institute  that  while  permanent  cures  can- 
not yet  be  claimed,  provisional  results  have  been  achieved 
which  "  show  encouraging  progress  in  the  therapy  of  the  ma- 
lignant neoplasms."  ^ 

In  all  Caan  reports  the  results  in  no  cases,  including  88  of 
carcinoma,  9  of  sarcoma,  8  of  generalized  lymphosarcoma,  and 
5  of  non-malignant  affections.  In  some  70  cases  the  treatment 
was  followed  by  notably  favorable  results.  In  30  cases  of 
recurrent  mammary  cancer  decided  improvement  occurred  in 
23  both  objectively  and  subjectively.  Of  14  cases  of  car- 
cinoma of  the  stomach  8  were  improved  especially  in  their  sub- 
jective condition,  though  only  exceptionally  was  the  ob- 
jective condition  bettered,  in  one  only  the  weight  increased. 
So  also  with  the  cancers  of  the  esophagus.  Of  rectal  can- 
cers 3  cases  were  on  the  whole  favorably  influenced,  as  also 
were  3  cases  of  inoperable  carcinoma  of  the  pharynx  which 
showed  a  strikingly  favorable  response  to  the  treatment.  Here 
in  one  case  a  tumor  as  large  as  a  plum  disappeared  in  four 

1  Concerning   the  Radium  Treatment   of   Malignant  Tumors.     Muen.' 
che7ier  Med.   IVoc/i.,  Oct.  19,  1909. 


TREATMENT   OF   CARCINOMA  AND   OTHER   TUMORS        64I 

Aveeks.  The  most  remarkably  favorable  results  were  ob- 
tained in  the  treatment  of  the  8  generalized  lymphosarcomas, 
in  all  of  which  there  was  a  decided  decrease  in  the  swellings 
and  in  several  of  them  a  complete  disappearance  of  the  tumors 
together  with  a  marked  gain  in  the  subjective  state.  The 
writer  ends  by  expressing  a  "  well-grounded  hope  in  spite  of 
all  scepticism "  in  view  of  the  experiences  described,  that 
"  with  the  help  of  radium  or,  still  better,  by  means  of  a  com- 
bination of  it  with  other  means,"  further  progress  can  be  made 
in  the  fight  against  the  malignant  tumors. 

Other  Recent  Therapeutic  Measures. — J.  W.  Vaughan,^  of 
Detroit  has  lately  reported  a  series  of  carcinoma  cases  treated 
by  the  injection  of  nontoxic  "  cancer-residue,"  preferably  pre- 
pared from  the  patient's  own  carcinoma.  The  aim  is  to  in- 
duce the  formation  in  the  body  of  a  ferment  capable  of  de- 
stroying the  growing  cancer  cells.  The  writer  is  conservative 
in  his  conclusions,  but  his  results  are  very  encouraging,  and 
should  certainly  stimulate  further  investigation  along  this  line. 

Bertrand  -  reports  the  apparent  cure  of  a  recurrent  car- 
cinoma and  marked  improvement  in  another  patient,  who  re- 
fused operation,  by  the  injection  of  an  emulsion  of  carcinoma- 
tous tissue  so  finely  divided  as  to  assure  the  disintegration  of 
every  cell  in  the  emulsion.  Bertrand's  method  is  somewhat 
similar  to  Vaughan's  in  principle,  and  his  results  are  therefore 
to  a  certain  extent  corroborative.    (See  also  note  on  page  651.) 

Trypsin  Treatment. — Various  investigators  have  reported 
upon  the  use  of  this  ferment.  Some  have  claimed  cures.  But 
the  majority  are  conservative  and  claim  only  palliative  im- 
provement. Pain  is  relieved  in  some  cases.  Nutrition  may 
be  improved  and  hemoglobin  increased.  Eosinophilia  is  in- 
duced, which  is  considered  an  evidence  of  increased  resistance. 
In  some  cases  the  injections  seem  to  cause  disintegration  of 
the  cancerous  tissue  in  the  center  of  the  mass,  but  the  periphery 
continues    to    grow.      (Bainbridge,    Med.    Record,    July    I'J, 

ly.  A.  M.  A.,  May  7,  1910,  p.  1510. 
^Gazette  Med.  Beige,  Mar.  31,  1910,  p.  252. 


642  THE    GASTRO-INTESTINAL    CLINIC 

1909.)  The  improvement  of  symptoms  may  justify  further 
trial  of  this  agent  in  inoperable  cases,  but  a  cure  is  hardly  to 
he  expected.  The  trypsin  is  administered  by  deep  hypodermic 
injection.  The  injections  may  be  alternated  with  injections 
of  amylopsin.  You  will  find  the  technic  detailed  in  the  cur- 
rent literature  on  the  subject. 

Thymus  Treatment. — F.  Gwyer  ^  has  used  powdered  thymus 
gland  in  doses  of  1.8  to  7  gm.  three  or  four  times  daily  in  a 
series  of  inoperable  carinomas,  and  reports  relief  of  pain 
and  diminution  in  the  size  of  the  growth. 

Early  Diagnosis  Indispensable. — Of  two  well-established 
truths  regarding  gastric  cancer  you  may  rest  assured :  ( i ) 
That  the  disease  cannot  at  present  be  cured  by  any  medicinal 
means;  and  (2)  that  surgery,  even  with  the  help  of  the  new 
and  remarkable  agents  above  mentioned,  will  be  equally  power- 
less with  medicine  to  effect  a  cure,  except  in  those  cases  in 
which  you,  with  possibly  the  help  of  medical  experts,  shall  have 
succeeded  in  accomplishing  two  difficult  things.  One  of  these 
is  to  make  a  probable  diagnosis  of  the  disease  at  a  very  early 
stage,  before  the  neighboring  glands  have  become  involved,  or 
strong  adhesions  have  bound  the  part  occupied  by  the  new 
growth  to  adjacent  organs,  and  usually  before  the  tumor  itself 
can  be  felt,  or  cachexia  has  developed.  The  other  is  to  induce 
the  patient  and  his  family  to  consent  to  an  exploratory  incision 
before  it  is  too  late.  You  should  remember  that  an  explora- 
tory incision  involves  very  little  risk,  when  done  after  all 
necessary  preparations  by  a  skillful  laparotomist  in  a  person 
who  is  still  well  nourished.  You  should  all  strive  to  acquire 
skill  in  physical  examination  and  special  training  in  the  recent 
methods  of  examining  the  stomach  as  to  its  size  and  position, 
and  also  as  to  its  motor  and  secretory  functions.  Even  with 
the  aid  of  these  methods  of  precision,  it  will  not  be  possible, 
always,  to  make  the  diagnosis  at  a  time  when  an  operation  can 
offer  hope  of  a  radical  cure;  but  it  sometimes  can,  and  with- 
out them  such  a  consummation  is  impossible.  ' 
'^  N.  Y.  Med.  four.,  Feb.  19,  1910. 


TREATMENT   OF   CARCINOMA  AND   OTHER   TUMORS        643 

Indications  for  an  Exploratory  Incision — Indeed,  whenever 
a  case  presents  the  symptoms  of  a  severe  chronic  gastric  ca- 
tarrh, with  or  without  the  absence  of  free  hydrochloric  acid, 
and  tliere  is  at  the  same  time  much  lactic  acid  present,  a  per- 
sistent pain  localized  in  the  stomach,  and  marked  loss  of  motor 
power  in  the  organ,  as  well  as  weakness  and  emaciation,  and 
these  symptoms  not  only  continue,  but  get  worse,  in  spite  of 
lavage,  appropriate  diet,  tonics,  and  digestive  aids,  not  longer 
than  three,  or  at  the  most  four  weeks,  should  be  wasted  in  ex- 
pectant treatment.  Under  these  circumstances,  the  susj^icion 
of  carcinoma  should  be  strong  enough  to  warrant  summoning 
the  best  obtainable  laparotomist  and  re-examining  the  patient 
thoroughly  under  an  anaesthetic.  This  might  reveal  an  in- 
cipient tumor  not  palpable  before;  also  sufficient  glandular  or 
other  complications  already  to  render  any  operation  inad- 
visable, or  to  limit  the  surgical  intervention  to  some  palliative 
procedure  merely.  But  supposing  that,  in  such  a  case,  under 
anaesthesia  no  contra-indications  should  be  found,  there  would 
be  warrant,  according  to  the  best  recent  authorities,  for  making 
an  exploratory  incision  with  preparations  for  some  remedial 
operation,  radical  or  palliative,  if  a  tumor  should  be  discovered. 

Operative  Treatment — An  operation  having  been  decided 
upon,  the  surgeon  may,  hopefully  extirpate  the  pylorus  (pylo- 
rectomy)  for  a  growth  in  that  region;  or  remove  any  other 
part  of  the  stomach,  or  even  the  whole  organ — gastrectomy,  in- 
complete or  complete.  Or,  if  a  cancer  obstructing  the  pylorus 
has  progressed  to  a  hopeless  stage,  a  direct  communication 
may  be  established  between  the  body  of  the  stomach  and  the 
small  intestine — gastro-enterostomy.  This  often  prolongs  life 
for  many  more  months,  and  gives  the  patient  increased  com- 
fort. When  a  tumor  obstructs  the  cardiac  orifice,  the  usual 
operation  is  gastrostomy,  which  consists  in  making  an  open- 
ing directly  into  the  stomach  through  the  abdominal  wall. 
Through  this  the  patient  can  be  fed  while  life  lasts.  Sounds 
can  sometimes  be  passed  and  the  stricture  be  thus  dilated  from 
below,  through  the  same  orifice. 


644  THE    GASTRO-INTESTINAL    CLINIC 

Medicinal  and  Palliative  Treatment. — Naturally,  you  will 
be  likely  to  look  upon  a  case  of  beginning  carcinoma  of  the 
Stomach  as  simple  indigestion,  or  catarrh,  and  treat  it  ac- 
cordingly. At  first,  before  cancer  is  even  suspected,  nothing 
better  could  \\'ell  be  done.  But  when  you  put  the  patient  upon 
thorough  and  appropriate  treatment,  you  have  reason  to  ex- 
pect improvement  if  no  more  serious  condition  exists  than  ner- 
vous dyspepsia,  or  even  a  moderate  gastric  catarrh,  with  the 
usually  accompanying  neurasthenia.  If,  instead  of  improve- 
ment, there  results  a  further  downward  progress,  which  is  not 
checked,  or  the  symptoms  are  only  temporarily  ameliorated, 
with  then  further  aggravation  in  spite  of  treatment,  even 
lavage  affording  slight  or  no  relief,  you  will  have  strong  reason 
for  suspecting  that  something  more  serious  is  the  matter.  You 
will,  in  that  case,  of  course,  leave  nothing  undone  that  will  help 
to  decide  whether  or  not  you  are  dealing  with  a  case  of  cancer 
in  a  stage  when  it  may  still  be  curable  by  surgical  meas- 
ures. You  should  then  proceed  as  already  advised  for  such 
cases. 

But  when  you  have  taken  the  alarm  too  late,  or,  if  not,  have 
failed  to  get  in  time  the  consent  of  the  patient  for  an  explora- 
tory incision,  some  palliative  operation  may  still  prolong  life, 
and  if  this  should  be  declined,  you  can  yet  do  much  by  medical 
treatment  to  defer  the  inevitable  fatal  termination,  and  render 
the  condition  of  the  patient  more  tolerable  while  he  lives. 

The  difficult  task  now  devolving  upon  you  will  be  : 

1.  To  relieve  the  accompanying  asthenic  gastric  catarrh, 
and  the  symptoms  dependent  upon  it,  including  the  nausea  and 
vomiting,  the  failure  of  the  secretion  of  HCl  and  of  the  fer- 
ments, and,  in  part,  the  lowered  nutrition. 

2.  To  combat  the  decreasing  gastric  motility  as  well  as  the 
anaemia,  debility,  and  emaciation. 

3.  To  control  hematemesis. 

4.  To  assuage  the  pain,  secure  sleep,  and  make  the  patient 
as  comfortable  as  possible. 

Dietetic  Treatment. — All  these  objects  may  be  promoted  to 


TREATMENT   OF   CARCINOMA   AND  OTHER   TUMORS         645 

a  considerable  extent  by  a  suitable  diet,  and  the  indications 
here  are  not  wholly  the  same  as  in  ordinary  chronic  gastric 
catarrh  of  asthenic  type,  except  when  this  is  complicated  by 
failing  motor  power  of  the  stomach.  The  weakened  motility, 
or  propulsive  power,  is  always  a  conspicuous  feature  of  ad- 
vanced gastric  carcinoma,  and  this  calls  imperatively  for  small 
and  relatively  frequent  feedings  with  the  blandest  and  most 
easily  digestible  nourishment.  In  probably  a  large  majority  of 
cases,  good,  fresh  milk,  in  some  of  its  forms  or  preparations, 
will  agree  best,  and  will  need  to  be  prominent  among  the  nutri- 
ments depended  on.  Usually  plain  sterilized  or  boiled  milk, 
with  1-12  to  1-4  part  limewater,  according  to  the  degree  of  ir- 
ritability, is  as  suitable  as  any  form,  if  digestives  are  given 
after  the  meals,  but  sometimes  it  agrees  much  better  when  pre- 
digested  or  peptonized.  Other  excellent  foods  for  aggravated 
cases  are  the  whites  of  eggs  beaten  up  in  water,  well-cooked 
gruels,  peptonized  or  not  as  found  necessary,  whey,  koumiss, 
gelatin,  the  juice  pressed  out  of  lightly  broiled  steak,  and 
vegetable  purees.  Any  of  the  liquid  foods  may  be  thickened 
by  the  addition  of  beef  powder  or  of  plasmon.  The  various 
proprietary  foods,  both  the  albuminous  and  non-albuminous 
kinds,  will  often  suit  well,  and  will  help  to  afford  variety  in  the 
worst  cases,  especially.  In  the  earlier  stages,  and  in  those  cases 
with  less  irritability  and  more  digestive  power,  stale  bread  or 
toast  and  butter,  crackers,  fish,  oysters,  hashed  lean  meat,  soft- 
boiled  or  poached  eggs,  thoroughly  cooked  cereals  (the  finer 
kinds),  with  milk  or  cream,  and  even  the  blander  vegetables  in 
which  the  starch  has  been  well  dextrinized  by  cooking,  may  be 
allowed,  but  all  these  should  be  finely  divided  before  eaten.  As 
to  beverages,  the  previous  habits  of  the  patient  will  often  de- 
cide. The  lighter  wines  in  small  quantities  may  add  slightly 
to  the  nutrition,  and  tea  and  coffee,  unless  they  specially  dis- 
turb the  stomach,  should  not  be  denied  to  patients  who  have 
been  accustomed  to  them,  though  they  should  be  taken  with- 
out sugar  whenever  fermentation  is  very  troublesome.  The 
richer  chocolates   will   almost   certainly   disagree,    and   often 


646  THE    GASTRO-INTESTINAL    CLINIC 

the  choicest  cocoa,  though  these  are  all  highly  nourishing.  An 
infusion  of  cocoa  shells  is  more  suitable,  and  there  is  no  ob- 
jection to  the  cereal  coffees  without  the  addition  of  sugar. 
Sugar,  being  the  most  fermentable  of  all  foods,  should  gen- 
erally be  avoided. 

As  the  disease  advances,  and  the  ability  of  the  stomach  to 
empty  itself  lessens  more  and  more,  the  amount  of  the  liquids 
taken  by  the  mouth  will  have  to  be  dim,inished — especially  the 
amount  taken  at  a  time.  It  will  seldom  be  well  to  allow  more 
than  half  a  pint  of  liquid  at  any  one  time  in  this  way,  and  much 
less  in  far  advanced  cases.  Toward  the  last  the  demand  of  the 
system  for  liquids  may  have  to  be  met  in  part  by  injecting 
water  into  the  bowels,  and  the  feeding  in  the  later  stages  may 
be  supplemented  by  nutrient  enemas. 

A  case  of  cancer  of  the  stomach  and  pancreas  is  reported  by 
A.  Martinet  ^  in  which  pain  and  vomiting  were  constant  until 
the  patient  was  given  a  kind  of  kefir  described  by  him  as 
"  Bulgarian  clotted  milk  prepared  with  Maia." 

1,  Treatment  of  Accompanying  Gastritis  and  its  Re- 
sults.— In  Lecture  XLVIII.  on  The  Treatment  of  Chronic 
Asthenic  Gastritis,  the  methods  applicable  in  endeavoring  to 
ameliorate  the  catarrhal  complication  of  gastric  carcinoma  are 
fully  discussed,  besides  some,  such  as  the  application  of  elec- 
tricity and  massage  to  the  abdomen,  and  various  forms  of  ac- 
tive exercise,  which  are  not  suitable  in  cancer  of  the  stomach, 
for  obvious  reasons.  In  a  disease  which  reduces  the  strength 
and  flesh  so  rapidly,  and  increases  markedly  the  retrograde 
tissue  metamorphosis,  the  strength  needs  to  be  consented  as 
much  as  possible,  and  exercise  should  be  limited  to  the  milder 
forms,  and  never  allowed  to  fatigue.  General  massage  and 
general  faradization,  avoiding,  as  a  rule,  the  epigastric  region, 
are,  however,  passive  forms  of  exercise,  which  should  be  help- 
ful to  the  nutrition  except  in  the  later  stages. 

Lavage  is  the  most  important  of  all  the  mechanical  forms  of 
treatment  and   in  the  cases  of  pyloric  obstruction,  with  re- 
^ Presse  mtd.,  Paris,  XIV,  No.  16.    Jot{r.  A.  M.  A..  May  5,  1906. 


TREATMENT   OF   CARCINOMA  AND   OTHER   TUMORS         647 

tention  and  dilatation,  it  is  indispensable.  It  will  do  more 
usually  to  relieve  the  nausea  and  vomiting,  and  to  lessen  most 
of  the  symptoms  resulting  from  the  gastritis,  than  any  other 
of  our  therapeutic  resources. 

Sweetnam  ^  has  found  cerium  oxalate  6  grains  combined 
with  lo  grains  of  bismuth  very  efficient  in  controlling  the 
vomiting  and  pain  from  cancer  as  well  as  from  other  forms 
of  gastric  disease. 

,  Condurango,  a  drug  largely  used  in  Germany,  and  less  by 
American  physicians,  is  believed  now  to  be  helpful  mainly  be- 
cause of  the  good  effect  it  has  upon  the  accompanying  gastritis. 
At  all  events,  there  is  much  testimony  from  many  sources  to 
the  effect  that  the  symptoms  may  all  lessen  in  severity,  the  ap- 
petite increase,  and  life  often  be  somewhat  prolonged  as  a 
result  of  persevering  with  a  course  of  condurango.  This  may 
be  given  in  the  form  of  the  fluid  extract  in  doses  of  a  dram  or 
more,  three  times  a  day,  or,  as  preferred  by  Ewald,  in  a  macer- 
ation decoction  to  which  he  advises  the  addition  of  appropriate 
doses  of  HCl  and  some  carminative.  Boas,  Riegel,  and  most 
German  writers  also  speak  well  of  this  remedy,  while  admit- 
ting that  in  bad  cases  it  often  fails  to  effect  even  temporary  im,- 
provement. 

2.  Measures  Against  the  Debility,  etc. — To  combat  the 
asthenic  condition,  in  addition  to  the  remedies  and  measures 
already  mentioned  as  helpful  for  the  gastric  catarrh,  including 
especially  lavage  with  cleansing  and  antiseptic  solutions  to 
lessen  the  auto-intoxication,  it  is  necessary  to  overcome  any  ex- 
isting constipation  with  preferably  douches  of  the  colon,  since 
they  do  not  irritate  the  stomach,  while  they  supply  needed 
water  to  the  body;  though,  when  moderate  doses  of  mild  laxa- 
tives prove  effective,  they  may  answer,  and  are  less  troublesome 
and  fatiguing.  Diarrhea  needs  a  more  careful  diet,  possibly 
antiseptic  colon  douches,  often  full  doses  of  bismuth,  and  some- 
times stronger  astringents  with  opium.  Iron,  arsenic,  and 
strychnine,  when  well  tolerated,  may  be  administered  to  enrich 
'^Dublin  Joiir.  of  Science,  February,  1906. 


648  THE    GASTRO-IXTESTIXAL    CLIXIC 

the  blood,  stimulate  appetite,  etc.,  preferably  in  small  and 
often  repeated  doses  to  avoid  irritation;  but  frequently  they 
will  do  most  good  with  least  harm  when  given  in  suppositories. 
In  cancer  obstructing  the  pylorus,  nothing  will  have  more 
effect  in  staying  the  progressive  dilatation  of  the  stomach  than 
lavage,  and  a  careful  regulation  of  the  diet  as  above  advised, 
but  strychnine  hypodermically  may  occasionally  do  something 
temporarily.  Intragastric  electricity,  which,  in  simple  atonic 
dilatation,  is  our  most  powerful  weapon,  is  ineffective  and  even 
harmful  here.  HCl  and  pepsin,  or  some  preparation  of 
papaya,  may  help  the  patient  to  digest  more  food. 

3.  To  Control  the  Hematemesis. — This  is  usually  much  less 
serious  in  cancer  than  in  ulcer  of  the  stomach,  and  may  be 
often  avoided  merely  by  enforcing  the  diet  above  outlined. 
W^hen  it  occurs  the  patient  must  be  kept  at  rest,  recumbent,  all 
food  by  the  mouth  stopped,  and  in  the  moderately  severe  cases 
the  patient  may  be  caused  to  swallow  frequently  small  pieces 
of  ice.  Sometimes  small  draughts  of  quite  hot  water  are  still 
more  efficient.  Twenty-  to  30-grain  doses  of  bismuth  in  a 
mixture  with  limewater,  and  a  little  essence  of  peppermint, 
may  next  be  tried,  and  these  are  very  eft'ective  also  in  vomit- 
ing and  diarrhea.  The  stronger  astringents,  as  ergot,  gallic 
acid,  etc.,  rarely  do  good  in  this  fonii  of  hemorrhage  when 
taken  by  the  mouth.  Ergotin  or  ergotol  promise  better. 
Three  to  5  grains  of  suprarenal  extract  may  be  given 
several  times  a  day.  Locally  applied,  this  remedy  has 
a  greater  astringent  effect  than  any  other  known.  In  the 
more  aggravated  cases,  it  is  safer  to  give  nothing  whate\'er  by 
the  mouth — not  e\-en  pellets  of  ice.  Adrenalin  chloride  may, 
in  proper  cases,  be  given  by  mouth — ten  to  fifteen  drops  of  the 
solution.  Some  have  used  it  hypodermically,  but  the  safety  of 
this  is  questionable,  as  the  raising  of  the  general  blood-pressure 
is  likely  to  more  than  offset  the  constriction  of  the  bleeding 
vessel. 

Calcium  chloride  is  given  in  lo-grain  doses,  in  water, 
every  three  or  four  hours;  or  Tremoliere's  solution  may  be 


TREATMENT  OF  CARCIXOMA  AXD  OTHER  TUMORS        649 

used.  This  is  a  5  per  cent,  gelatin  solution  containing  2  per 
cent,  calcium  chloride.  One-half  to  one  ounce  may  be  given 
every  four  hours;  or  gelatin  alone  in  5  to  10  per  cent,  solution, 
may  be  administered  in  small  frequent  doses  by  mouth.  A  2 
per  cent,  solution  of  gelatin,  sterilized,  may  be  given  by  hypo- 
dermoclysis,  three  or  four  ounces  at  each  injection. 

4.  To  Relieve  the  Pain — External  applications  will  some- 
times relieve  the  pain  of  gastric  cancer.  ^lustard,  painting 
with  iodine,  liniments,  and  hot  wet  packs  are  the  most  easily 
applied,  and  will  sometimes  suffice.  Among  the  milder  in- 
ternal sedatives,  chloral  and  cannabis  indica  are  frequently 
effective  in  allaying  the  pain  and  procuring  increased  sleep, 
and  the  former  has  useful  antiseptic  as  well  as  sedative  vir- 
tues. Condurango  is  believed  by  various  authors  also  to 
ameliorate  the  pain  along  with  most  of  the  symptoms.  Boas 
praises  potassium  iodide,  especially  in  carcinoma  of  the  cardia, 
and  arsenic  is  thought  to  help  often  in  malignant  growths  any- 
where. ]^Iethylene  blue  has  accjuired  some  reputation  on  ac- 
count of  its  supposed  sedative  properties  in  gastric  cancer. 
Jacobi  claims  that  it  even  prolongs  life.  It  is  to  be  given 
in  doses  of  3  to  5  grains,  in  a  capsule  daily,  and  V'an  Valzah 
and  Xisbet  advise  that  a  little  powdered  nutmeg  be  com- 
bined with  it  "  to  correct  its  slightly  irritant  action  on  the 
urinary  tract."  Marcus  Fay  recommends  aniline  sulphate, 
holding  that  it  delays  metastasis  and  cachexia  and  relieves  the 
pain  better  than  opium.  But  sooner  or  later,  in  all  cases, 
opiates  will  become  necessarv'.  They  can  be  given  in  any  of 
the  usual  ways,  but  will  be  most  effective  hypodermically. 
Codein  should  be  preferred  so  long  as  it  continues  to  prove 
efficient,  but  at  all  events  the  patient  should  be  made  com- 
fortable. 

In  a  series  of  seventeen  cases  of  inoperable  carcinoma,  in- 
cluding two  of  the  stomach,  Bra  of  Paris,  and  Mongour  of 
Bordeaux,  have  reported  (Medical  Reviezv  of  Reviews,  April 
25,  1900),  some  remarkably  favorable  palliative  results  from 
injecting  a  purified  culture  of  the  nectria  ditissima,  a  parasitic 


650  THE    GASTRO-INTESTINAL    CLINIC 

growth  found  on  trees  and  considered  a  kind  of  vegetable 
cancer. 

Treatment  of  Sarcoma  and  Benign  Tumors. — The  treat- 
ment of  sarcoma  need  differ  ^"ery  little  from  that  of  carci- 
noma of  the  stomach,  except  that  even  greater  efforts  should 
be  put  forth  to  make,  at  the  earliest  possible  moment,  the 
diagnosis  of  malignancy,  so  as  to  secure  operative  interven- 
tion at  the  only  time  when  it  can  be  of  any  possible  use. 

In  the  inoperable  cases  Coley's  fluid  (the  mixed  toxins  of 
streptococcus  Erysipelatis  and  Bacillus  Prodigiosus)  should  be 
given  a  thorough  trial.  Coley  ^  reports  fifty-two  cases  of  in- 
operable sarcoma  successfully  treated  by  this  method.  The 
duration  of  the  cure  varied  from  three  and  one-fourth  to  six- 
teen years. 

There  is  reason  for  hope  that  a  curative  serum  will  be  pro- 
duced in  the  not  distant  future.  Ewing  -  states  that  in  nine 
consecutive  cases  a  malignant  sarcoma  in  dogs  has  been  cured 
by  bleeding  the  animal  and  transfusing  it  with  the  blood  of 
dogs  immunized  to  this  tumor.  The  ablest  pathologists  in 
ever}'  country  of  the  world  are  giving  their  best  efforts  to  the 
solution  of  the  cancer  problem — its  cause,  its  diagnosis,  and 
its  cure — and  it  is  to  be  fervently  hoped  that  the  problem  will 
soon  be  solved. 

Riegel  advises  the  administration  of  arsenic  in  h^mphosar- 
comatosis,  though  I  do  not  know  of  any  reports  of  cases  in 
which  it  has  proved  of  any  avail. 

The  treatment  of  the  benign  tumors  of  the  stomach  must 
be  almost  exclusively  surgical.  It  is  not  likely  that  galvan- 
ism, which  can  accomplish  so  much  for  such  growths  in  the 
pelvis,  could  be  employed  in  sufficient  strength  within  the 
stomach  to  be  efficient. 

In  every  swelling  or  apparent  tumor  of  the  pyloric  region, 
producing  symptoms  of  obstruction,  an  operation  at  tlie 
earliest  possible  moment  is  the  imperative  indication.     In  cer- 

i\V.  B.  Coley;  Practitioner,  London,  Nov.  1909. 
''■Journal  A.  M.  A.,  Jan.  22,  1910,  p.  269. 


TREATMENT   OF   CARCINOMA  AND   OTHER  TUMORS         65 1 

tain  cases  something  might  be  accomphshed  in  a  palHative  way 
by  dilating  the  pylorus  through  the  stomach  as  recommended 
bv  Hemmeter ;  but  it  is  true  conservatism  here  to  insist  upon 
radical  measures  promptly — gastro-enterostomy,  pyloroplasty, 
or  pylorectomy. 

Injection  of  Ascitic  Fluid  from  a  Recovered  Case  of  Cancer. 
— Hodenpyl/  pathologist  to  the  Roosevelt  Hospital,  New 
York,  made  during  the  current  year  (1910)  a  preliminary  re- 
port on  the  treatment  of  carcinoma  by  the  injection  of  ascitic, 
fluid  from  a  practically  recovered  case  of  the  same  disease  into 
or  near  the  tumor  after  several  removals  and  recurrences. 
He  reported  in  brief  that  forty-seven  human  cases,  mostly 
"  distinctly  unfavorable,  many  of  them  hopeless  and  inoper- 
able," had  been  treated  in  this  way.  The  effect,  he  stated, 
was  "  nearly  uniformly  to  induce  a  temporary  local  redness, 
tenderness,  and  swelling  about  the  tumors,  which  soon  subside. 
Then  occur  softening  and  necrosis  of  the  tumor  tissue,  which 
is  now  absorbed  or  discharged  externally,  with  the  subsequent 
formation  of  more  or  less  connective  tissue.  In  all  cases  the 
tumors  have  grown  smaller;  in  some  they  have  disappeared 
altogether."  Dr.  Hodenpyl  died  of  pneumonia  shortly  after 
making  this  most  interesting  report,  and  his  collaborators  have 
not  yet  reported  as  to  the  further  results. 

Coca  and  Oilman  2  report  a  series  of  14  cases  of  carcinoma,  some  f^r 
advanced,  nearly  all  of  which  were  apparently  cured  by  the  injection  of  a 
single  dose  of  an  extract  of  the  patient's  own  carcinoma  partly  or  wholly 
removed  by  operation  the  same  day  as  the  injection.  The  injections  were 
followed  in  a  few  days  by  the  softening  and  absorption  of  the  portions  of 
the  tumor  left  behind.  This  apparent  cure  had  lasted  several  months  in 
some  cases,  the  patients  having  had  no  recurrence  up  to  the  time  of  their 
report.  This  method  is  now  being  tested  by  other  observers,  in  Los 
Angeles  and  other  Pacific  coast  cities. 

^N.  V.  Med.  Record,  Feb.  26,  1910. 

2  Coca  and  Q\\ma.n—Phtltppme  Jour,  of  Science,  Dec,  1909. 


LECTURE  LXIII 
TUMORS  OF  THE   INTESTINES 

CARCINOMA   AND    SARCOMA 

Cancer  of  the  intestines  is  an  infrequent  disease,  especially 
in  the  parts  above  the  rectum.  In  some  large  series  of  cases 
nearly  90  per  cent,  of  such  cancers  were  in  the  rectum.  It  is  a 
singular  fact  that  while  carcinomas  are  much  more  frequent 
in  the  stoiiiach  than  in  any  other  part  of  the  digestive  system, 
and  comprise  nearly  one-half  of  all  cancers  found  anywhere 
in  the  human  body,  they  are  least  common  in  the  small  in- 
testine, and  the  frequency  of  their  occurrence  in  the  intestinal 
tube  is  in  direct  proportion  to  the  distance  below  the  stomach. 
The  explanation  of  the  fact  that  cancer  so  much  oftener  at- 
tacks the  stomach  and  rectum  than  other  portions  of  the 
digestive  system  is  that  these  regions  suffer  most  from  irrita- 
tion— the  stomach  from  indigestible  and  insufficiently  chewed 
food,  and  the  rectum  from  the  pressure  of  impacted  feces. 
The  other  sites  where  such  growths  are  found  with  compara- 
tive frequency  are  in  the  cecum  and  the  flexures  of  the  colon, 
including  the  sigmoid,  all  of  these  being  places  where  the 
feces  are  prone  to  lodge. 

Intestinal  cancer  seems  to  be  a  little  more  common  in  men 
than  in  women.  It  is  most  prevalent  in  middle  and  advanced 
age.  as  in  the  case  of  similar  growths  in  the  stomach. 

The  disease  is  generally  primary  in  the  intestines,  but  may 
extend  to  them  by  contiguity  from  adjacent  organs,  or  ex- 
ceptionally, by  metastasis.  Sarcoma  of  the  intestines  is  very 
much  rarer  even  than  carcinoma. 

.Etiology. — The  origin  of  carcinoma  and  of  sarcoma  is 
still  unknown,  and  I  will  not  attempt  to  repeat  here  all  the 

652 


TUMORS    OF    THE    INTESTINES  653 

guesses  upon  the  subject.  There  is  much  evidence,  however, 
going  to  show  that  various  forms  of  trauma — direct  injury  to 
the  tissues  or  irritation  of  any  kind  long  continued — predispose 
to  both  kinds  of  mahgnant  neoplasms,  especially  in  persons 
having  impaired  constitutions,  whether  the  impairment  be  in- 
herited or  acquired.  Infection  may  also  have  to  do  with  the 
production  of  sarcoma  and  carcinoma. 

Metastases. — Cancers  of  the  intestine  are  less  disposed  than 
those  of  any  other  parts,  according  to  Ewald  and  various 
other  authorities,  to  spread  or  reproduce  themselves  by  metas- 
tasis, and  when  this  does  occur,  it  is  more  likely  to  be  late 
in  the  case.  This  is  exceedingly  important  and  should  en- 
courage you  to  advise,  and  even  urge,  surgical  intervention 
whenever  the  disease  can  be  diagnosed  before  it  has  advanced 
to  a  manifestly  fatal  extent. 

Metastasis  in  these  cases  is  most  frequently  to  the  lymph- 
glands  of  the  peritoneum.  Ewald  has  observed  that  next 
after  these,  the  tendency  is  to  involve  the  liver,  and  then  the 
peritoneum  itself,  the  lungs,  the  uterus,  etc. ;  also,  that  in 
cancer  of  the  flexures  of  the  colon,  the  infection  tends  most 
toward  the  lumbar  glands,  and,  in  that  of  the  transverse  colon, 
to  the  omental  glands.  Such  pointers  from  an  exceptionally 
experienced  pathologist  and  clinician  are  valuable.  The  same 
author  cautions  us  not  to  forget  that  the  existence  of  cancer 
in  the  bowels  does  not  exclude  the  possibility  of  another  pri- 
mary growth  of  the  kind  in  some  other  part  at  the  same  time. 
Both  sarcoma  and  lymphosarcoma  are  almost  invariably  pri- 
mary when  they  involve  the  intestines,  and  they  are  more 
prone  to  invade  other  parts  by  metastasis  than  carcinoma. 

Pathology. — The  several  varieties  of  carcinoma  which  occur 
in  the  stomach  or  elsewhere  may  also  be  encountered  in  the 
intestines.  The  adenocarcinoma  predominates.  The  colloid 
form  is  often  found  in  the  rectum,  and  less  frequently  the 
pavement-celled  cancroid  variety.  Again,  as  in  the  stomach, 
intestinal  cancer  may  be  hard  (scirrhus)  or  soft  (colloid),  and 
beginning  usually  in  the  mucosa,  tends  to  develop  outwards 


654  THE    GASTRO-INTESTINAL    CLINIC 

through  the  other  layers  successively.  The  disease  shows  a 
great  tendency  also  to  extend  itself  around  the  entire  circum- 
ference of  the  bowel,  producing  ring-shaped  or  sometimes 
cylindric  thickenings,  which  result  in  partial  or  complete  ste- 
nosis. The  intestine  above  these  narrowed  parts  becomes  dilated 
— often  even  when  the  obstruction  is  not  complete — and  Ewald 
has  seen,  at  autopsy,  pouches  thus  produced  as  large  as  the 
stomach.  The  scirrhous  form  has  a  marked  tendency  to  ulcer- 
ate with  the  production  of  small  quantities  of  pus  and  blood, 
which  may  be  found  in  the  stools,  and  when  a  vessel  is  thus 
eroded,  larger  hemorrhages  may  result.  Perforation  is  not 
infrequently  caused  by  such  ulceration,  and  in  this  way  gen- 
eral peritonitis  may  be  get  up,  or  more  commonly  when  ad- 
hesions have  attached  the  diseased  intestine  to  a  neighboring 
structure,  local  peritonitis  develops;  or  the  perforation  may 
produce  a  fistulous  connection  between  the  intestine  and  the 
stomach,  or  other  adjacent  viscus.  Local  peritonitis  may  also 
result  from  the  extension  of  the  growth  through  to  the  peri- 
toneum. The  formation  of  a  gastrocolic  fistula  through  the 
perforation  of  a  cancer,  in  either  the  stomach  or  transverse 
colon,  gives  rise  to  a  peculiar  group  of  symptoms,  which  are 
described  in  Lecture  LIX. 

The  pathology  of  sarcoma  and  lyiuphosarcoiiia  in  the  intes- 
tines does  not  differ  from  that  of  the  same  growths  as  found 
in  the  stomach.  All  the  varieties  of  these  tumors  may  be  en- 
countered here,  but  the  small  round-celled  sarcoma  is  most 
frequent.  They  usually  take  their  origin  in  the  submucosa 
and  extend  to  the  muscular  and  serous  layers  of  the  gut.  The 
lymphosarcoma  arises  from  either  the  solitary  or  agminated 
lymph  follicles.  The  most  frequent  site  of  sarcoma  is  in  the 
duodenum  or  rectum.  It  is  asserted  by  numerous  authorities 
that  sarcoma  of  the  intestine,  in  contrast  with  carcinoma,  en- 
larges by  its  growth  the  lumen  of  the  bowel,  instead  of  lessen- 
ing it;  but  this  is  certainly  not  always  the  case. 

Symptomatology. — Gradually  increasing  debility,  anaemia, 
cachexia,  and  emaciation,  with  usually,  but  not  alwavs  loss  of 


TUMORS    OF   THE    INTESTINES  655 

appetite,  are  general  symptoms  of  malignant  growths  in  any 
part  of  the  body.  Naturally  these  symptoms  do  not  appear  to 
any  noticeable  extent  at  the  very  outset  of  the  disease.  The 
tumor  must  have  progressed  for  weeks,  and  sometimes 
months,  before  they  have  become  prominent  enough  to  attract 
the  attention  of  the  patients  or  their  friends.  There  are  not 
certain  to  be  any  symptoms  or  signs  which  could  lead  you  even 
to  suspect  either  a  cancer  or  sarcoma  anywhere  in  its  incipi- 
ency,  and  in  so  far  as  concerns  such  a  tumor  in  the  intestines, 
it  is  more  likely  there,  than  elsewhere,  to  run  a  latent  course 
for  a  long  time. 

Pain  is  the  symptom  most  commonly  thought  of  in  connec- 
tion with  malignant  neoplasms.  Cancer  of  the  intestines  is 
painful,  as  a  rule,  but  the  pain  is  often  quite  moderate  and 
tolerable  until  a  far  advanced  stage,  and  is  often  diffuse,  re- 
ferred vaguely  to  a  large  part  of  the  abdomen,  or  to  the  lower 
back.  It  is  comparatively  seldom  limited  to  the  locality  of  the 
tumor.  It  is  frequently  not  persistent,  but  spasmodic,  like 
neuralgia.  In  cancer  of  the  flexures,  the  pain  is  often  felt  in 
the  hip  joints  or  loins,  but  in  such  cases  the  pain  may  change 
about,  being  felt  sometimes  in  one  place,  and  again  in  another. 
Then,  in  a  certain  proportion  of  carcinomas,  and  in  a  still 
larger  proportion  of  sarcomas  of  the  intestines,  no  pain  may  be 
complained  of  until  very  near  the  end.  The  pain  is  often  due 
to  adhesions,  and  to  the  dragging  which  results  upon  adjacent 
organs,  especially  during  exercise  or  while  massage  is  being 
given. 

The  Unding  of  a  tumor  by  palpation  is  the  chief  sign  of  an 
intestinal  neoplasm.  This  is  rarely  possible  at  an  early  stage, 
and  when  the  growth  is  in  certain  positions,  such  as  in  the 
flexures,  which,  with  the  exception  of  the  rectum,  are  the  most 
frequent  sites  of  intestinal  cancer,  you  will  not  often  be  able  to 
feel  it  before  it  has  attained  to  a  large  size.  Tumors  of  the  in- 
testine, except  they  be  in  the  lowest  part  of  the  duodenum,  or 
in  tlie  cecum  or  rectum,  or  have  become  attached  by  adhesive 
inflammation   to   some   neighboring   part,   are   more  or  less 


656  THE    GASTRO-INTESTINAL    CLINIC 

movable,  and  can  be  pushed  from  side  to  side.  When  they 
arise  from  the  transverse  colon,  or  its  flexures,  or  from  the 
small  intestine,  except  the  third  portion  of  the  duodenum,  they 
very  commonly  pull  the  bowel  down  by  their  own  weight  into 
the  pelvis  after  they  have  attained  to  a  considerable  size.  In 
palpating  the  abdomen,  therefore,  you  should  be  careful  to  feel 
thoroughly  every  inch  of  it,  including  especially  the  lowest 
zone.  You  should  never  neglect  to  examine  per  rectum,  and 
in  women  per  vaginam  as  well,  by  bimanual  palpation,  since 
in  this  way  tumors  otherwise  undiscoverable,  attached  to  va- 
rious parts  of  the  intestine,  may  be  recognized.  When  rigid- 
ity of  the  abdominal  muscles  prevents  satisfactory  palpation, 
you  may  need  to  etherize  the  patient,  but  examination  in  a 
warm  bath  will  sometimes  cause  relaxation. 

Malignant  neoplasms  in  the  intestines  after  the  earlier 
stages  are  generally  somewhat  sensitive  to  pressure,  though  by 
no  means  always — Ewald  says  most  of  them  are  but  slightly 
so.  When  there  is  a  local  low-grade  peritonitis,  from  a  slowly 
developed  perforation,  the  tenderness  will  extend  for  a  little 
distance  on  all  sides  from  the  site  of  the  tumor.  Quite  fre- 
quently in  the  case  of  cancer,  it  has  been  observed  that  there  is 
a  slight  oedema  under  the  surface  of  the  overlying  region. 
The  tumor  is  at  first  smooth  and  oval  or  roundish  in  form,  but 
the  carcinomatous  kind  are  likel}^  soon  to  become  irregularly 
knobbed,  so  as  to  present  an  uneven  surface.  Sarcoma  is 
usually  smooth  and  hard  throughout,  and  grows  at  a  phenome- 
nally rapid  rate. 

The  temperature  in  cancer  is  rarely  above  normal,  until  the 
growth  begins  to  ulcerate,  and  is  often  subnormal.  When  dis- 
integration is  in  progress,  there  may  be  chills  and  fever. 
Fever  is  more  frequently  observed  in  sarcoma. 

The  stools  do  not  present  any  uniform  appearance  char- 
acteristic of  malignant  growths  in  the  bowel,  unless  pieces  of 
tissue  found  upon  a  microscopic  examination  contain  evi- 
dences of  malignancy;  and  this  does  not  often  happen.  Small 
amounts  of  pus  or  blood,  or  still  more,  both  at  once,  may 


TUMORS    OF    THE    INTESTINES  657 

awaken  suspicion  of  a  growth,  and  would  be  to  a  certain  extent 
confirmatory  in  case  a  tumor  could  be  felt;  but  the  various 
forms  of  intestinal  ulceration  give  the  same  findings. 

There  may  be  regular  normal  evacuations  until  the  lumen 
of  the  bowel  is  so  much  narrowed  that  hardened  feces,  gall 
stones,  or  a  bunch  of  worms  produces  complete  obstruction. 
Not  infrequently  a  persistent  diarrhea  complicates  the  disease 
from  first  to  last,  or  there  may  be  either  constipation  or  normal 
stools  at  times,  alternating  with  diarrhea.  In  the  case  of  car- 
cinoma, sooner  or  later  obstruction  of  the  bowel  nearly  always 
occurs  as  a  result  of  a  gradually  increasing  encroachment 
upon  its  lumen.  This  is  finally  closed  completely  by  an  ob- 
turation from  within — most  commonly  in  the  form  of  an  ac- 
cumulation of  hard  fecal  masses  or  undigested  substances  in 
the  dilated  pouch  above.  Sometimes  such  an  accumulation 
may  be  forced  through  the  stricture  once  or  even  oftener,  by 
purgatives  aided  by  atropine,  olive  oil,  or  perhaps  metallic 
mercury,  but  at  last  the  obstruction  recurs  and  cannot  again  be 
overcome  by  anything  short  of  laparotomy. 

For  some  time  before  the  final  obstruction  suddenly  brings 
such  a  grave  and  generally  fatal  crisis  in  the  case,  the  stools, 
•when  the  tumor  occupies  the  colon,  may  give  evidence  of  the 
existence  of  a  permanent  stricture,  by  being  constantly  rib- 
bon-formed, or  of  lead-pencil  size  and  shape.  According  to 
some  authors,  stools  composed  of  small,  hard  balls,  like  bullets 
(Schafkoth) may  also  point  to  such  a  stricture,  but  such  stools 
as  the  last  mentioned  are  very  common  in  torpid  liver  or 
sluggish  bowel — constipation — from  various  causes.  The  rib- 
bon-like or  pencil-formed  stools  may  occur  as  a  result  of 
spasmodic  contractions  in  certain  neurotic  conditions  (see  the 
description  of  spastic  constipation  in  Lecture  LXIX.),  but 
in  such  cases  the  stools  will  usually  be  at  times  of  normal  size 
and  form,  especially  after  full  doses  of  nerve  sedatives,  while, 
when  the  stricture  is  due  to  a  tumor,  a  normal  stool  is  never 
possible. 

QEdema  of  the  feet  and  legs  is  very  commonly  present,  and 


658  THE    GASTRO-INTESTINAL    CLINIC 

sometimes  ascites,  during  the  latter  part  of  a  course  of  a 
malignant  tumor  in  the  abdomen,  as  a  result  of  the  obstructed 
return  flow  of  the  blood.  The  former  symptom  often  disap- 
pears a  short  time  before  death.  The  ascites  frequently  re- 
sults from  the  involvement  of  the  peritoneum  in  the  malignant 
process. 

Distention  of  the  abdomen  generally,  or  of  particular  loops 
of  the  intestines,  does  not^  differ  in  the  cases  under  considera- 
tion from  the  same  symptom  when  resulting  from  other  forms 
of  bowel  obstruction.  It  simply  points  to  obstruction,  though 
the  persistent  inflation  of  a  certain  loop  may  help  to  locate 
the  trouble. 

Disturbances  of  digestion  may  be  absent,  or  at  least  not 
marked  in  tumors  of  the  lower  bowel  until  the  disease  is  far 
advanced,  but  even  in  these  cases  there  generally  develop  pari 
passu  with  the  cachexia  and  debility,  a  falling  off  in  appetite 
and  an  increasing  difficulty  in  the  digestion  of  a  normal 
amount  of  food.  Very  commonly  there  is  a  distaste  for  meat ; 
often  also  nausea  and  vomiting  as  well  as  the  diarrhea  already 
referred  to.  When  the  tumor  is  in  the  small  intestine,  espe- 
cially if  near  the  stomach,  the  obstruction  resulting  tends  to 
produce  gastrectasis  with  its  peculiar  train  of  symptoms,  the 
same  as  when  it  involves  the  pylorus.  In  most  of  the  cases  as- 
sociated with  failing  or  absent  appetite,  the  gastric  juice  will 
be  found  very  deficient  in  HCl,  and  often  in  the  ferments 
as  well. 

A  malignant  tumor  of  the  colon  causes  more  disturbance  of 
the  bowels,  flatulence,  colic,  etc.,  with  generally  constipation, 
or  an  alternation  of  this  with  diarrhea. 

Cancer  of  the  rectum,  the  most  frequently  encountered  of 
intestinal  neoplasms,  is  considered  in  the  special  lecture  on 
Diseases  of  the  Rectum  and  Anus,  but  will  be  referred  to 
here  briefly.  In  this  region  you  have  the  very  great  ad- 
vantage of  being  able  to  make  a  certain  diagnosis,  both  by  the 
touch  and  by  sight,  with  the  help  of  a  good  speculum.  The 
pain  of  both  cancer  and  sarcoma  here  is  usually  worse  than  in 


TUMORS    OF    THE    INTESTINES 


659 


those  higher  up  in  the  bowel,  and  is  increased  during  defeca- 
tion. Tenesmus  is  also  a  marked,  and  often  a  most  distressing 
symptom.  When  the  tumor  is  not  recognized  in  time,  its 
ravages  by  direct  extension  to  the  adjacent  pelvic  structures 
are  likely  to  be  serious,  but  fortunately  metastasis  does  not,  as 
a  rule,  occur  early,  and  when  the  patient  applies  for  medical 


Fig.  81. — Ulcerating  carcinoma  of  the  rectum  with  the  formation  of  pouches 
and  sinuous  invaginations  of  the  mucous  membrane.  (After  Quenu  et 
Hartmann.) 


advice  reasonably  soon,  the  diagnosis  should  be  made  promptly 
enough  to  warrant  hopeful  treatment. 

The  symptoms  of  intestinal  sarcoma  differ  from  those  of 
carcinoma  by  ( i )  the  much  greater  energy  and  rapidity  of  its 


66o  THE    GASTRO-INTESTINAL    CLINIC 

growth;  (2)  the  very  much  greater  size  to  which  it  may  at- 
tain, notwithstanding  that  it  kills  so  much  more  quickly;  (3) 
the  markedly  rapid  development  of  cachexia,  debility,  and  the 
other  signs  of  constitutional  involvement;  (4)  the  far  shorter 
duration  of  life  after  the  disease  develops  (usually  less  than 
a  year)  ;  (5)  the  comparatively  great  rarity  of  intestinal 
hemorrhage  during  its  course;  (6)  the  infrequency  of  any  re- 
sulting intestinal  obstruction,  in  consequence  of  the  fact, 
stated  by  most  authors,  that  it  causes  dilatation  rather  than 
contraction  of  the  bowel  at  the  point  attacked,  and  (7)  the 
almost  uniformly  smooth  surface  of  the  tumor  itself. 

In  addition  to  the  foregoing  important  and  well-defined  dif- 
ferences, Boas  mentions  also,  as  of  possible  value,  the  early 
development  of  ascites  in  sarcoma,  and  irregular — sometimes 
regular — fever  in  the  same  disease. 

Regarding  sarcoma  of  the  rectum,  its  objective  symptoms  or 
signs  differ  decidedly  from  those  of  carcinoma  of  the  same  re- 
gion in  two  noteworthy  respects  :  ( i )  The  tumor  can  be  felt 
as  smooth  and  not  nodulated;  and  (2)  ulceration  or  disin- 
tegration, which  nearly  always  speedily  develops  in  epithe- 
lioma everywhere,  is  commonly  absent  in  sarcoma  of  the 
rectum,  and  this  can  be  quickly  determined  positively  by  a 
digital  examination. 

Course  and  Complications. — The  duration  of  cancer  of  the 
intestines  is  longer  on  the  average  than  that  of  the  same  dis- 
ease elsewhere — often  three  or  four  years  when  uncomplicated. 
It  begins  very  insidiously  and  pursues  a  comparatively  latent 
course  in  many  of  the  cases.  Besides  such  frequent  accidents 
as  intestinal  hemorrhage,  diarrhea,  etc.,  cancer  here  finally 
always  invades  the  peritoneal  layer  of  the  bowel,  and  then 
there  may  result  any  one  of  a  variety  of  complications — local 
peritonitis  with  adhesions  to  any  adjacent  organ  or  other  in- 
testinal coil ;  perforation  with  a  resulting  localized  abscess 
or  general  peritonitis.  By  such  perforations  fistulas  may  be 
established  between  the  loop  of  intestine  involved  and  some 
neighboring  one,  with  the  stomach  (as  in  gastrocolic  fistula), 


TUMORS    OF    THE    INTESTINES  66 1 

with  the  bladder,  gall  bladder,  etc.  Or  in  the  same  way  a 
fistulous  opening  may  occur  through  the  abdominal  wall. 
Qidema  of  the  lower  extremities  or  effusion  into  the  peritoneal 
cavity — ascites — may  occur. 

When  operative  intervention  is  not  invoked  sufficiently 
early,  cancer  of  the  intestines  most  frequently  effects  its  fatal 
result  by  causing  obstruction  of  the  bowels,  with  the  conse- 
quent autotoxgemia  and  almost  incessant  vomiting.  In  the 
absence  of  obstruction  death  comes  from  exhaustion  as  a 
result  of  the  toxaemia,  and  often  in  coma — coma  carcino- 
matosum. 

In  cancer  of  the"  duodenum  or  jejunum,  as  in  pyloric  cancer, 
death  results  much  sooner  than  when  its  seat  is  lower  in  the 
alimentary  canal,  since  digestion  is  seriously  embarrassed,  and 
nutrition  suffers  more. 

Sarcoma,  in  both  its  forms,  runs  a  rapid  course  in  the  in- 
testines as  elsewhere  (though  a  very  rare  disease  there)  and 
does  its  fatal  work  within  nine  months  or  a  year — often  in 
less  time.  Kundrat  of  Vienna,  whose  experience  has  been 
largest  in  this  disease,  and  whose  figiuTS  all  authors  cite,  in- 
sists that  it  does  not  generally  cause  any  stenosis  of  the  bowel, 
but  the  opposite  condition  of  dilatation.  All  its  characteristic 
phenomena,  already  referred  to,  develop  much  more  quickly 
than  in  the  case  of  carcinoma. 

Diagnosis. — The  differential  diagnosis  between  carcinoma 
and  sarcoma  in  the  intestines  (unless  the  tumor  is  in  the 
rectum)  can  rarely  be  made  at  once,  when  the  case  first  comes 
under  medical  oversight.  But  after  any  doubtful  tumor  has 
been  carefully  observed  for  a  few  weeks,  it  ought  usually  to 
be  possible  to  decide  which  form  of  tumor  is  present  from  the 
rate  of  growth,  the  feeling  of  it,  the  degree  of  development  of 
cachexia,  etc.,  and  by  the  other  differences  mentioned  under  the 
head  of  Symptomatology.  This  is  an  important  diagnosis  to 
make,  since  surgical  intervention  is  generally  to  be  urged  in 
intestinal  carcinoma,  except  when  metastases  are  demon- 
strable,  but   rarely  advisable   in  sarcoma   after  a   tumor  is 


662  THE    GASTRO-INTESTINAL    CLINIC 

clearly  palpable,  for  the  reason  that  other  parts  are  then 
almost  certain  to  have  been  already  attacked  by  it. 

You  may  certainly  diagnose  cancer  or  sarcoma  of  the  in- 
testines, only  when  you  can  either  find  the  elements  of  such 
a  growth  in  the  stools  along  with  some  other  decided  symptom 
or  sign  of  the  same,  such  as  a  tumor  or  steady  loss  of 
flesh,  strength,  and  color  in  spite  of  remedies  which  should 
have  checked  such  a  tendency,  or  find  a  tumor  connected  with 
the  bowel,  together  with  such  marked  symptoms  of  failing 
health  as  above  mentioned,  especially  when  there  are  also 
symptoms  of  gradually  increasing  intestinal  obstruction,  point- 
ing then  to  carcinoma. 

Finding  any  of  these  symptoms  alone,  or  even  all  of  them 
without  being  able  either  to  make  out  a  tumor,  or  discover 
the  elements  of  a  malignant  growth  in  the  stools,  should 
render  you  suspicious  and  watchful,  but  cannot  be  decisive. 
Various  other  conditions,  such  as  a  stricture  from  a  healed 
ulcer,  chronic  appendicitis,  adhesions,  twists,  and  other 
causes  of  intestinal  obstruction  might  produce  similar  symp- 
toms. 

To  determine  in  what  part  of  the  intestines  a  tumor  is  sit- 
uated, you  may,  in  any  case  which  has  not  progressed  so  far 
with  disintegration  as  to  endanger  a  rupture,  inject  carbonic 
dioxide,  air,  or  a  warm  weak  saline  solution  into  the  colon. 
These,  in  case  of  a  complete  occlusion  of  the  intestine  by  the  tu- 
mor, will  be  arrested  at  the  site  of  the  latter.  In  any  case,  the 
injection  of  air  or  gas  will  distend  the  colon,  and  thus  help  you 
by  means  of  percussion  to  determine  more  nearly  the  location 
of  the  growth  when  it  is  in  the  large  bowel.  This  would  aid 
little,  however,  in  fixing  the  location  of  a  tumor  of  the  small 
intestine,  except  by  exclusion.  You  will  need  to  differentiate 
between  a  malignant  neoplasm  of  the  bowel  and  the  following 
especially:  a  hard  fecal  tumor;  a  kidney  fixed  in  a  wrong 
place ;  a  benign  tumor  connected  with  one  of  the  pelvic  organs, 
intestines,  or  other  abdominal  viscera;  an  encapsulated  peri- 
toneal exudation;  a  tuberculous  growth  in,  or  adjacent  to,  the 


TUMORS    OF    THE    INTESTINES 


663 


bowel ;  actinomycosis  in,  or  near,  the  same ;  a  scar  and  thick- 
ening which  may  have  resulted  from  a  healed  ulcer  of  any 
kind,  whether  syphilitic,  tubercular,  dysenteric,  or  as  a  com- 
plication of  chronic  intestinal  catarrh  or  typhoid  fever. 

To  discuss  here  in  extenso  the  diagnosis  of  a  malignant 
tumor  of  the  intestines  from  each  of  the  above-mentioned  con- 
ditions, would  require  more  space  than  is  at  my  disposal.  But 
with  regard  to  most  of  them  the  diagnosis  is  easy,  since  the 
steadily  increasing  cachexia,  debility,  etc.,  of  cancer  are  almost 
never  present  in  any  of  them,  except  possibly  those  involving 
tuberculosis,  and  this  could  be  differentiated  quickly  by  the 
tuberculin  test  (see  Lecture  LVL).  Actively  progressing 
syphilis,  too,  might  mislead,  but  this  would  speedily  respond  to 
the  fullest  practicable  doses  of  the  iodides. 

To  decide  whether  a  growth  in  the  cecum  is  carcinomatous 
or  tubercular  is  sometimes  very  difficult,  and  Boas,  in  his 
"  Darmkrankheiten,"  has  given  the  following  tabular  state- 
ment of  the  differential  diagnosis  between  the  two  conditions : 

DIFFERENTIAL  DIAGNOSIS   BETWEEN  TUBERCULOSIS  AND 
CARCINOMA  OF  THE  CECUM 

Carcinotna  of  the  Cecum. 

Seldom  before  the  fourth  decade. 


Tuberculosis  of  the  Cecum. 
Age 


Generally  in  the  second 
to  fourth  decade. 


Duration.  Very  chronic. 

Ltcngs.  Often  show  more  or  less 
decided  tubercular 
processes. 

Tumor.  Shows  a  marked  extent 
in  length;  also  the 
bowel  itself,  in  conse- 
quence, can  be  felt  as 
an  infiltrated  organ. 

Signs  of  Always  present  and  dis- 
Stenosis.       tinguished  by  decided 
sounds. 

Stools.  Contain  blood  and  pus 
very  seldom,  but  often 
tubercle  bacilli. 

Fever.     Not  seldom  present. 


Urine. 


Shows   Ehrlich's    diazo 
reaction. 


That  usually  of  cancer  generally. 
Negative. 


Is  sharply  circumscribed  and  usu- 
ally limited  strictly  to  the  cecum. 
This  cannot  be  palpated  as  such 
at  all. 


May  be  wholly  wanting.  If  pres- 
ent, less  markedly  audible  than 
in  cecal  tuberculosis. 

Blood  and  pus  not  rarely  observed. 
Tubercle  bacilli  never  found. 


Exceptional. 

Always  fails  to  show  the  diazo  re- 
action. 


664  THE    GASTRO-INTESTINAL    CLINIC 

Other  Diagnostic  Points. — Fecal  tumors  have  often  been 
confounded  ^vith  malignant  growths,  and  the  diagnosis  is 
•sometimes  impossible  at  first,  or  till  after  a  patient  use  of 
aperients,  especially  oil  and  warm  saline  solutions  by  enema, 
has  had  time  to  soften  a  fecal  mass,  as  well  as  to  diminish  its 
size,  and  often  to  change  its  position. 

When  the  fecal  tumor  has  not  by  long  pressure  inflamed  the 
adjacent  mucosa  so  as  to  be  very  sensitive  to  pressure,  and  at 
the  same  time  is  not  very  hard,  the  diagnosis  can  sometimes 
be  made  at  once  by  denting  it  with  the  finger  through  the  ab- 
dominal wall,  or  even  breaking  it  in  two ;  but  this  is  very  often 
impracticable.  Then  the  only  way  is  to  administer  purgatives 
or  enemas  and  aw^ait  results. 

Another  rather  difficult  condition  to  differentiate  from  an 
intestinal  cancer  or  sarcoma,  and  yet  one  in  which  it  is  very 
important  to  be  able  to  make  the  diagnosis,  is  that  in  which  one 
of  the  kidneys — usually  the  right  one — has  been  displaced  and 
become  fixed  by  inflammatory  adhesions  in  an  abnormal  po- 
sition, especially  in  the  case  of  a  much  weakened  and  emaci- 
ated patient,  with,  as  not  infrequently  happens,  Bright's  disease 
developing  as  a  complication.  Here,  the  surest  help  to  the 
diagnosis  would  be  a  radiograph.  But  careful  palpation  in  the 
gentlest  manner,  Avhen  the  tumor  can  be  plainly  felt,  should 
reveal  the  peculiar  kidney  form  when  it  constitutes  the  tumor. 
Furthermore,  the  pallor  of  simple  anaemia  or  of  Bright's  dis- 
ease is  different  from  the  yellowish  dirty-white  of  cancer. 
Then  a  patient  with  a  misplaced  kidney,  plus  Bright's  dis- 
ease, or  neurasthenia,  will  generally  improve  when  put  to  bed 
and  carefully  fed,  but  not  often  with  cancer  or  very  tempo- 
rarily, when  the  loss  of  flesh  and  strength  will  again  progress. 

It  is  frecpiently  still  more  difficult  to  diagnose  cancer  or 
sarcoma  of  the  intestines  from  a  like  tumor  of  some  other  ab- 
dominal organ,  but  this  is  far  less  important,  except  for  the 
purposes  of  prognosis.  In  so  far  as  regards  treatment,  it  makes 
comparatively  little  difference  what  particular  abdominal 
structure  is  involved.     If  the  tumor  should  be  far  advanced, 


TUMORS    OF    THE    INTESTINES  665 

speedy  death  would  be  inevitable  anyway;  and  if  it  were 
recent,  with  the  patient  in  fair  condition,  an  exploratory  inci- 
sion would  be  desirable  in  any  event  unless  the  growth  occu- 
pied one  of  a  very  few  situations,  such  as  the  cardiac  orifice  of 
the  stomach,  the  liver,  the  pancreas  (except  impracticably 
early),  and  possibly  one  or  two  other  viscera,  or  parts  of  vis- 
cera, which  the  surgeons  would  not  risk  invading.  To  reach  a 
diagnosis,  which  should  exclude  a  tumor  of  one  of  these  parts, 
is  generally  quite  possible  from  the  symptoms  and  the  results 
of  a  thorough  examination. 

Prognosis  and  Treatment. — It  is  still  generally  believed 
that  there  is  no  sure  remedy  for  either  carcinoma  or  sarcoma, 
but  that  the  surest  is  very  early  removal  by  the  knife.  This  is 
doubtless  true  when  the  tumor  is  in  a  safely  accessible  situa- 
tion and  when  both  the  diagnosis  can  be  made,  and  consent  to 
an  operation  obtained,  at  a  very  early  stage  of  the  disease 
before  any  metastasis  or  glandular  involvement  has  occurred. 
But  several  rivals  of  the  knife  are  now  coming  forward  in  this 
field.  One  of  them  is  Massey's  semi-surgical  method  of  driv- 
ing into  the  diseased  tissue  certain  caustic  metallic  salts  by 
the  help  of  colossal  doses  of  the  continuous  current  (galvan- 
ism) under  anesthesia.  This  method  is  described  in  its  dis- 
coverer's own  language  in  Lecture  LXXIX.,  page  928. 

Massey  claims  exceptional  success  for  this  method,  and  re- 
ports numerous  cures  effected  by  means  of  it  in  cancer  of  the 
rectum  and  in  other  accessible  cavities.  Other  physicians  also 
are  reporting  well  of  it. 

Fulguration — Another  measure  much  debated  in  Con- 
tinental literature  is  "  fulguration,"  originated  by  de  Keating- 
Hart  of  Marseilles.  This  consists  in  the  application  of  the 
spark  of  a  high-frecjuency  current  of  high  tension  to  the  ma- 
lignant growth.  Very  favorable  reports,  including  cures  of 
inoperable  cases,  are  given  by  the  originator  and  some  of  his 
followers.  Others  condemn  the  method  very  positively,  but 
its  actual  value  is  yet  to  be  determined. 

The  x-ray,  violet  ray,  Finsen  light,  radium,  etc.,  have  all 


666  THE    GASTRO-INTESTINAL    CLINIC 

been  employed  of  late,  and  some  of  them,  with  alleged  suc- 
cess, in  malignant  tumors  of  the  rectum  as  well  as  in  other 
cavities  of  like  easy  access;  in  cancer  of  the  breast  and  uterus 
and  in  innumerable  morbid  growths  of  the  skin.  See  Lecture 
LXII.  on  The  Treatment  of  Carcinoma  and  other  Tumors 
of  the  Stomach. 

The  approved  surgical  operations  in  malignant  intestinal 
neoplasms  are,  (i)  when  there  is  hope  of  extirpating  the 
disease  altogether,  an  excision  of  that  part  of  the  gut  which 
includes  the  growth,  followed  by  an  end-to-end  anastomosis 
of  the  severed  parts  of  the  bowel,  and  (2)  when  this  is  no 
longer  possible,  avoidance  of  further  irritation  of  the  diseased 
tissues  by  joining  a  healthy  loop  of  intestine  above  to  another 
below  (entero-enterostomy  or  entero-colostomy),  and  then 
making  an  opening  between  them;  or  when  the  tumor  is  high 
up  in  the  small  intestine,  the  same  object  may  be  better  ob- 
tained by  attaching  a  loop  of  intestine  below  it  to  the  stomach 
— gastro-enterostomy.  ^  (3)  When  the  tumor  is  in  the  rectum, 
or  lower  part  of  the  colon,  and  none  of  the  above  operations 
is  practicable,  the  establishment  of  an  artificial  anus  in  the 
colon  (colostomy)  may  still  be  done  with  the  prospect  of  pro- 
longing life  thereby. 

In  Lecture  LXXIX.  the  various  procedures  practicable  in 
malignant  disease  of  the  rectum  are  discussed. 

The  palliative  treatment  of  malignant  neoplasms  in  the  in- 
testines does  not  differ  essentially  from  that  of  cancer  of  the 
stomach  as  described  in  Lecture  LXIL  just  mentioned.  When 
the  bowels  are  loose,  the  methods  described  in  the  Treatment 
of  Diarrhea — Lecture  LXXL — will  be  applicable;  and  when 
there  is  constipation  the  very  full  account  of  the  best  methods 
of  overcoming  it,  as  described  in  Lecture  LXX. — especially 
the  employment  of  oil,  both  by  mouth  and  by  enema — will 
stand  you  in  good  stead. 

When  the  bowels  are  becoming  obstructed  by  a  tightening 
stricture,  caution  needs  to  be  used  in  the  administration  of 
the  stronger  cathartics,  since  these  may  sometimes  do  serious 


TUMORS    OF    THE    INTESTINES  667 

harm.  Lashing  the  intestines  to  greater  efforts  may  produce 
a  rupture  of  the  dilated  pouch  above  the  stricture  and  speedy 
death. 

When  surgery  is  impracticable,  the  better  plan  is  to  depend 
upon  liquid  diet,  aided  by  nutritive  and  laxative  enemas,  such 
as  saline  solutions,  molasses,  and  milk,  etc.,  and  give  olive  oil 
freely  when  it  is  well  borne,  or  if  not,  liquefy  the  feces  by  a 
cautious  employment  of  the  purgative  salts,  or  natural  waters. 

BENIGN   TUMORS  OF  THE   INTESTINES 

Other  neoplasms  than  cancer  and  sarcoma  rarely  occur  in 
the  bowels,  except  in  the  form  of  small  polypi  which  cannot  be 
recognized  and  seldom  produce  symptoms.  The  different  va- 
rieties which  may  develop  there  are  cyst  adenoma,  (which  is 
the  predominant  kind,)  fibroma,  lipoma,  myoma,  and  angioma. 
When  any  of  these  are  attached  to  the  mucosa  by  a  distinct 
pedicle  they  constitute  polypi.  They  do  not  often  give  rise 
to  any  derangement  of  function,  except  that,  when  large,  they 
sometimes  cause  bleeding.  Occasionally,  too,  they  have  been 
a  cause  of  intussusception.  Small  growths  or  excrescences  of 
these  kinds  are  sometimes  very  numerous  in  certain  portions  of 
the  intestines,  especially  in  children. 

The  most  common  form  of  them  is  the  adenoma.  This 
takes  its  origin  in  the  mucosa,  is  prone  to  occur  in  groups,  and 
is  acini  form  in  structure. 

Treatment. — When  benign  tumors  of  the  intestines  give 
rise  to  hemorrhage  which  cannot  be  controlled  by  astringents, 
laparotomy  is  necessary,  as  it  may  be  also,  occasionally,  for 
obstruction  or  intussusception  (invagination)  from  the  same 
cause.  Such  tumors  are  most  frequently  encountered  in  the 
rectum,  and  are  there  more  amenable  to  treatment  than  else- 
where.    (See  Lecture  LXXIX.) 


LECTURE  LXIV 

INTESTINAL    OBSTRUCTION 

There  are  many  conditions  which  by  interfering  with  the 
passage  of  ingesta  or  flatus  through  the  intestines  produce 
either  partial  or  complete  obstruction  of  the  bowels.  It  seems 
best  for  descriptive  purposes  to  treat  the  subject  under  the  two 
general  heads  of — 

I.  Acute  intestinal  obstruction.  II.  Chronic  intestinal  ob- 
struction. 

As  a  rule  when  there  is  complete  occlusion  the  obstruction 
is  accompanied  by  acute  symptoms,  and  when  the  occlusion  is 
partial  the  symptoms  are  subacute  or  chronic  in  character. 
Exceptionally,  however,  complete  obstruction  may  come  on 
very  gradually  and  for  a  time  present  no  acute  symptoms ;  on 
the  other  hand,  a  partial  obstruction  may  be  accompanied  by  a 
sudden  stoppage  of  the  circulation  with  acute  symptoms. 

Acute  intestinal  obstruction  or  Ileus  may  he  divided  into — 

1.  Congenital. 

(  (a).  Adynamic. 

2.  Acquired.  }  (b).  Dynamic. 

((c).  Mechanical. 

The  most  common  congenital  malformations  are  imperforate 
anus,  absence  of  the  anus  and  lower  end  of  rectal  pouch,  mal- 
formations of  the  colon,  and  constriction  of  the  bowel  from 
intra-uterine  peritonitis.  These  are  all  easily  recognized,  and 
with  the  exception  of  the  imperforate  anus,  are  generally  rap- 
idly fatal. 

(a).  The  adynamic  type  (those  cases  primarily  producing 
a  loss  of  propulsive  power)  generally  follows  some  injury  to 
the  spine  or  to  Auerbach's  and  Meissner's  plexus  of  nerves 

668 


INTESTINAL   OBSTRUCTION  66g 

situated  within  the  intestinal  wall.  It  may  be  produced  re- 
flexly  from  a  disturbance  of  the  peripheral  nerves  supplying- 
the  intestines,  mesentery  and  omentum.  Inflammatory  lesions 
of  the  lungs  and  pleura  are  known  to  sometimes  cause  in- 
testinal paresis,  and  two  interesting  cases  have  been  recently 
reported  by  Dr.  J.  E.  Adams  of  London,  England,  where  it 
was  produced  apparently  from  an  irritation  of  the  splanchnic 
nerves,  the  result  of  a  fracture  of  the  ribs. 

(b).  The  dynamic  type  (those  cases  primarily  producing  ex- 
cessive power  or  contraction)  forms  an  extensive  group  of  dis- 
eases frequently  encountered.  They  are  generally  compli- 
cated secondarily  by  a  local  or  general  peritonitis.  But 
there  are  some  infections  so  virulent  in  character  that  they 
paralyze  the  bowel  and  overwhelm  the  patient  before  the  de- 
velopment of  peritonitis.  There  are,  on  the  other  hand,  less 
virulent  ones  which  do  not  produce  peritonitis  at  all,  but  re- 
flexly  cause  the  bowel  to  become  obstructed.  Under  the  lat- 
ter class  may  be  included  great  accumulations  of  gas,  various 
traumatisms,  such  as  operations  upon  the  genital  organs,  the 
intestines,  compression  of  a  testicle,  replacement  of  hernias, 
strangulation  of  pieces  of  omentum  or  powerful  irritation  of 
the  peritoneum  from  any  cause,  and  even  hysteria  may  occa- 
sionally produce  it. 

Embolism  or  thrombosis  of  the  superior  mesenteric  artery 
constitutes  a  rare  case  of  ileus,  but  one  which  produces  a  very 
early  gangrene  of  the  affected  segment.  The  destruction  of 
tissue  is  so  rapid  that  the  intestine  is  usually  dark,  friable,  and 
gangrenous  before  the  patient  comes  to  operation.  Individu- 
als in  whom  it  occurs  generally  have  some  endocardial  disease, 
which  may  show  itself  by  a  murmur  at  the  apex.  According 
to  the  experiments  of  Deckart,  the  reason  for  the  rapid  march 
of  the  gangrene  is  to  be  found  in  the  fact  that  the  vessels  of 
the  intestinal  walls  are  in  a  sense  like  end  arteries.  While 
there  is  a  rich  anastomosis  between  the  vessels  of  the  walls 
of  the  small  intestine,  yet  the  connecting  branches  are  very 
small,  and,  after  the  lodging  of  an  embolus,  the  blood  pressure 


670  THE    GASTRO-INTESTINAL    CLINIC 

is  SO  low  that  an  infarct  is  formed,  and  the  tissue  breaks  down 
before  the  'collateral  circulation  can  be  established.  For- 
tunately this  accident  is  very  rare. 

(c)  The  mcclianical  (those  resulting  from  strangulation, 
compression  or  obturation),  including  the  strangulation  of 
hernias;  intussusception;  volvulus;  kinking  of  the  bowel;  peri- 
toneal adhesions  and  the  pressure  of  neoplasms;  obstruction  of 
the  lumen  of  the  bowel  by  enteroliths,  foreign  bodies,  etc. 

The  Symptoms  of  Dynamic  Obstruction. — Since  the  va- 
rious causes  of  intestinal  obstruction  differ  so  widely  from  one 
another,  and  since  many  of  them  present  distinctive  symptoms 
which  are  peculiar  and  not  common  to  the  others,  it  will  be 
best  to  describe  separately  under  each  group  of  setiologic  con- 
ditions   its  characteristic  symptomatology. 

Syiupfojiis  of  Intestinal  Obstruction  Generally. — Let  me 
premise,  however,  that  in  every  case  of  complete  obstruction 
of  the  bowels,  there  is  obstinate  constipation — obstipation. 
There  also  develop,  sooner  or  later,  the  inevitable  conse- 
quences of  such  a  condition,  viz.,  pain,  A^omiting,  which  in 
time  becomes  fecal,  and  great  tympany  or  meteorism.  There 
will  also  be  found,  as  a  rule,  indicanuria,  and  a  marked  leuco- 
cytosis.  Unless  relief  comes  within  a  comparatively  few  days, 
the  time  depending  upon  the  vitality  of  the  patient,  the  part  of 
the  intestines  obstructed  and  the  extent  of  the  traumatic  in- 
jury involved,  death  ensues  either  from  shock  or  from  septic 
poisoning,  starvation,  and  exhaustion.  Within  a  few  hours 
often  after  the  pain  and  vomiting  have  become  severe,  the 
patient  will  be  veiy  pale,  with  pinched  features,  a  haggard, 
anxious  expression,  and  a  very  restless  manner,  while  the  pulse 
in  mqst  cases  will  be  weak  and  rapid,  rarely  under  125  or  130, 
and  often  much  higher — 150  to  160. 

The  symptoms  of  ileus  due  to  acute  peritonitis,  either  local 
or  general,  are,  in  addition  to  those  above  mentioned  which  are 
common  to  all  forms,  the  following,  which  are  characteristic 
of  the  inflammatory  affection  itself. 

Besides  acute  spontaneous  pain,  there  is  very  marked  pain 
on  pressure,  the  affected  part  of  the  abdomen  becoming  ex- 


INTESTINAL    OBSTRUCTION  6)^1 

quisitely  tender.  Vomiting  is  nearly  always  an  early  symp- 
tom. \Mien  general  peritonitis  exists,  the  patient  remains 
almost  immovable,  lying  on  one  side  or  in  the  dorsal  decubi- 
tus, with  the  knees  drawn  up  to  prevent  the  pressure  of  the 
bed-clothes,  and  breathes  in  a  shallow  way  to  avoid  the  in- 
creased pain  that  a  deep  depression  of  the  diaphragm  would 
cause.  In  this  form  of  the  disease,  too,  the  pulse  is  rapid, 
usually  1 20  to  150  to  the  minute,  very  small,  and  often 
thready.  There  is  fever  in  nearly  all  cases,  though  exception- 
ally this  may  be  absent  in  some  of  the  gravest  cases,  and  in 
spite  of  the  usual  high  central  temperature,  especially  in  the 
rectum,  the  skin,  of  the  extremities  particularly,  is  generally 
cold  and  clamm}'. 

In  general  peritonitis,  after  a  short  time,  an  effusion  takes 
place,  and  liquid  may  be  demonstrated  in  the  abdominal  cavity 
in  dependent  positions.  WHien  there  has  been  perforation  into 
the  peritoneal  cavity,  the  hepatic  dullness  disappears  in  the 
mammary  line,  and  may  be  absent  in  other  cases  of  obstruc- 
tion in  consequence  of  coils  of  intestines  having  been  crowded 
up  over  the  liver. 

The  Symptoms  of  Dynamic  Obstruction  from  other  Causes. 
— These  do  not  call  for  extended  description.  When  a  com- 
pressed testicle,  operations  upon  the  intestines,  attempts  at 
replacement  of  a  hernia,  etc.,  reflexly  produce  paralysis  or 
paresis  of  the  bowels,  the  symptoms  are  less  violent  as  a  rule. 
AMien  the  cause  can  be  removed,  they  usually  do  not  persist 
long,  unless  the  traumatism  has  set  up  peritonitis. 

When  disease  of  the  central  nervous  system  or  hysteria  pro- 
duces a  paralytic  ileus,  the  symptoms  are  those  of  the  setio- 
logic  affection  plus  those  of  obstruction  in  general.  Great  ac- 
cumulations of  gas,  from  autox?emia  or  other  infections  short 
of  peritonitis,  give  rise  to  a  paresis  of  the  bowel  which  is 
usually  mild  in  comparison  with  those  which  result  from 
either  peritoneal  infection,  or  any  of  the  mechanical  causes. 
Pain,  more  or  less  stubborn  constipation,  anorexia,  debility, 
and  auccmia,  with  occasional,  but  not  often  persistent  or  vio- 


6/2  THE    GASTRO-INTESTINAL    CLINIC 

lent  vomiting,   complete  the  picture  in  such  a  form  of  ob- 
struction in  which  the  parent  trouble  can  be  remedied. 

The  symptoms  of  a  mesenteric  infarct  are  a  very  sudden 
development  of  the  clinical  complex  characteristic  of  ileus  gen- 
erally, with  at  first  large,  ill-smelling  stools,  which  are  dark 
and  tarry  from  their  contained  blood.  There  are,  also,  acute, 
severe  pain,  great  sensitiveness  to  pressure,  vomiting,  etc., 
the  usual  symptoms  of  peritonitis,  which  grow  very  rapidly 
worse.  In  addition  there  is  generally  an  exudate  into  the  peri- 
toneal cavity,  which  gravitates  into  the  flanks,  and  often  be- 
sides, symptoms  of  a  concomitant  endocarditis.  Death  often 
closes  the  scene  before  fecal  vomiting  has  occurred. 

MECHANICAL  OBSTRUCTION 

The  mechanical  varieties  of  intestinal  obstruction  shall  be 
here  divided  as  follows : 

1.  Intussusception,  the  most  frequent  cause,  which  usually 
produces  both  (a)  strangulation  by  a  compression  of  the 
mesentery  as  well  as  of  the  vessels  in  the  bowel  itself,  thus 
cutting  off  the  circulation  of  the  part,  and  (&)  obturation, 
the  segment  of  gut  which  forms  the  intiissiisceptum  acting  as 
a  plug  and  closing  the  lumen  more  or  less  completely.  In- 
tussusception thus  usually  produces  both  strangulation  and 
obturation. 

2.  Those  forms  in  which  there  is  sudden  occlusion  of  the 
intestine  by  some  kind  of  external  strangulation,  as  in  vol- 
vulus, or  torsion  of  an  intestinal  loop ;  the  strangulated  her- 
nias, whether,  through  the  usual  openings  in  the  abdominal 
wall  into  slits  of  the  mesentery,  omentum,  etc.,  or  behind  a 
persisting  Meckel's  diverticulum  whose  free  end  has  become 
adherent  to  some  adjacent  structure;  and  knotting  of  a  por- 
tion of  the  intestine  by  long  peritoneal  bands. 

3.  Obstruction  by  any  one  of  various  outside  agencies  as 
follows:  A  sharp  flexure  in  the  intestine  from  the  downward 
displacement  of  the  stomach  or  a  portion  of  the  intestine  it- 
self; the  pressure  of  neoplasms  attached  to  the  outer  wall  of 


INTESTINAL    OBSTRUCTION 


673 


the  gut,  or  to  some  neighboring  structure ;  and  the  pressure  of 
displaced  organs,  such  as  the  kidney  (especially  the  right 
one),  the  liver,  uterus,  ovaries,  etc. 

4.   Obturation  by  gall  stones,  intestinal  concretions   {enter- 
oliths), accumulations  of  zvornis,  foreign  bodies  which  have 


Fig.  82. — Intussusception  of  the  jejunum;  a,  internal;  b,  intermediate;  c, 
external  cylinder;  d,  mesentery. — (From  "  Klinik  der  Verdauungs- 
krankheiten,  "  von  Prof.  Dr.  C.  A.  Ewald.) 

been  swallowed,  masses  of  hardened  feces,  polypi  growing 
from  the  intestinal  mucosa,  and  exceptionally  other  benign 
tumors  inside  the  bowel. 

5.  Strictures  or  stenoses  which  may  result  from  the  scars 


6/4  THE    GASTRO-INTESTINAL    CLINIC 

of  ulcers — peptic,  syphilitic,  tubercular,  dysenteric,  or  catar- 
rhal— and  from  carcinoma,  which  last  usually  causes  an  an- 
nular infiltration  of  the  bowel  wall,  with  a  gradual  thickening 
of  the  latter,  and  a  consequent  narrowing  of  the  lumen. 

The  conditions  described  in  i  and  2  usually  develop  acute 
symptoms  which  may  come  on  very  rapidly,  though  intussus- 


LOWER  FOLD  OF 
'/LEOCeCAL  VALVF 


APPENDIK 


Fig.    83. — Ileocolic  intussusception.      A.      Point  at  which  invagination 

began. 

ception  sometimes  fails  to  produce  complete  occlusion,  and 
may  set  up  a  chronic  condition,  in  which  there  are  occasional 
acute  exacerbations.  Those  described  under  3  and  4  may,  or 
may  not  cause  acute  obstruction  with  violent  symptoms.  The 
conditions  mentioned  under  5 — the  stenoses  and  strictures — 
generally  come  on  gradually,  and  the  symptoms  of  obstruction 
are  rarely  acute  till  late  in  the  case,  after  mild  disturbances, 
pain,  constipation,  etc.,  slowly  increasing,  have  long  given 
warning.  They  will,  thereiore,  be  considered  under  the  head 
of  Chronic  Obstruction. 

Intussusception. — The  most  common  cause  of  mechanical 
obstruction  is  intussusception.  This  may  be  classified  into  two 
chief  varieties,  enteric  and  colic.    An  enteric  intussusception  is 


INTESTINAL    OBSTRUCTION  6/5 

a  condition  in  which  one  portion  of  the  small  intestine  has  pro- 
lapsed or  telescoped  into  another  part  of  the  same.  A  colic 
intussusception  presents  a  similar  state  of  affairs,  except  that 
the  invagination  is  limited  to  the  colon,  and  the  small  gut 
plays  no  part  therein.  There  may  also  be  a  mixed  variety  in 
which  the  small  bowel  prolapses  into  the  larger,  producing  a 
subvariety  of  enteric  intussusception. 

There  are  two  chief  forms  of  this  subvariety :  viz.,  ileocolic 
and  ileocecal.  By  the  term  ileocolic  is  meant  an  intussuscep- 
tion which  begins  in  the  small  bowel  and  protrudes  through 
the  ileocecal  valve  into  the  colon.  This  condition  is  illus- 
trated in  Fig.  82.  An  ileocecal  intussusception  might  be  con- 
sidered as  only  a  subvariety  of  the  ileocolic,  and  is  one  in 
which  the  beginning  of  the  intussusception  was  at  the  ileo- 
cecal valve.  That  is  to  say,  the  first  part  to  prolapse  is  the 
valve,  which  drags  after  it  a  portion  of  the  ileum.  It  is  prob- 
able that  many  cases  diagnosed  as  ileocecal  are  really  not  intus- 
susceptions in  which  the  site  of  the  primary  invagination  is 
the  ileocecal  valVe,  but,  as  has  been  shown  by  Corner,^  the 
original  difficulty  was  located  at  some  point  just  above  the 
valve  in  the  wall  of  the  ileum,  and  this  primary  invagination  is 
lost  sight  of  as  it  passes  through  the  valve  into  the  colon.  In 
this  form  the  primary  invagination  may  unroll  itself  as  it 
passes  into  the  cecum.  Many  intussusceptions  are  double,  /.  e., 
the  first  intussusccptum  and  intussiiscipiens  together  form  a 
new  intussiisceptiim  for  a  second  invagination.  Corner  be- 
lieves that  about  80  per  cent,  of  all  intussusceptions  are  double, 
and  an  analysis  of  his  observations  tends  to  confirm  his  con- 
clusions. It  is  easy,  for  instance,  to  overlook  a  primary  en- 
teric invagination,  beginning  close  to  the  valve  and  unrolling 
itself  into  the  cecum  as  it  progresses.  This  fault  in  observa- 
tion would  greatly  decrease  the  number  of  double  intussuscep- 
tions reported.  The  table  of  the  varieties  of  intussusception 
given  by  Corner  is  well  worth  study,  and  is  here  reproduced  in 
full: 

'  Brit.  Med.  Jour.,  October,  1903. 


6^6 


THE    GASTRO-INTESTINAL    CLINIC 


Variety 

Probable  Frequency- 

Definition 

Single. 

I. 

Enteric   . 

Uncommon. 

Small  gut  into  small  gut. 

2. 

Ileocolic  . 

Rare  by  itself. 

Enteric  through  valve. 

3- 

Ileocecal. 

Uncommon. 

Originates  at  valve. 

4- 

Colic  .     . 

Probably  most  common 
single  intussusception. 

Large  gut  into  large  gut. 

Double. 

I. 

D  ouble- 
enteric    . 

Rare. 

Enteric  into  small  gut. 

2. 

Ileocolic- 

Most  common  of  all. 

Ileocolic  "impacted"  in  valve^ 

colic    . 

cecum  invaginated  into 
colon. 

3- 

E  nteric- 

Very  rare. 

Double  enteric  with  one  part 

ileocolic  . 

prolapsed  through  valve. 

4- 

Enteric- 

Second    most    frequent 

Enteric  pushing  valve  in  front 

ileocecal. 

variet3^ 

of  it. 

5- 

Ileocecal- 
colic    .     . 

Very  rare. 

Colic  into  large  gut. 

6. 

D  o  uble- 
colic    .     . 

Rare. 

Colic  into  large  gut. 

7- 

Colic -ileo- 

Fairly common. 

Caput   coli   or    cecum   invagi- 

cecal .     . 

nated  iirst  blocking  the 
valve,  this  causing  ileocecal 
intussusception. 

Intussusceptions  of  the  appendix  are,  of  course,  to  be  classed 
with  those  beginning  in  the  caput  coH  and  are  probably  quite 
rare.  The  only  case  in  which  any  cause  for  an  invagination  of 
the  appendix  could  be  found  was  reported  by  Rolleston,  and 
is  quoted  in  Corner's  paper.  In  this  case  there  was  a  prolapse 
evidently  started  by  a  concretion  present  in  the  appendix. 
This  had  probably  caused  an  exaggerated  peristalsis. 

Intussusception  of  Meckel's  Diverticulum This  is  of  rare 

occurrence,  and  some  of  its  varieties  might  very  properly  be 
classified  with  hernias.  Accordingly  as  the  diverticulum  is  or 
is  not  connected  with  the  umbilicus,  there  will  be  possible  two 
quite  distinct  accidents.  If  the  diverticulum  is  attached  only 
to  the  bowel,  it  may  become  invaginated  into  the  ileum  in 
very  much  the  same  manner  as  the  appendix  is  inverted  into 
the  cecum.  This  accident  is  only  rarely  possible  because 
Meckel's  diverticulum,  when  present,  is  nearly  always  attached 
to  surrounding  structures,  a  circumstance  which  would  en- 
tirely prevent  its  invagination  into  the  ileum.  The  cases  in 
which   this   variety   of    intussusception   has   occurred   usually 


INTESTINAL    OBSTRUCTION 


^77 


o-ave  histories  of  subacute  disturbances  followed  by  an  acute 
attack,  which  last  was  due  to  an  acute  secondary  intussuscep- 
tion of  the  ileum  caused  by  the  small  gut  grasping  the  inverted 


Fig.  84. — Invaginated  Meckel's  diverticul-um,  with  stenosis  and  perforation 
of  the  small  intestine;  a,  cicatricial  contraction  with  perforation;  b, 
mesentery  of  the  diverticulum  which  has  been  in  part  retracted  into  the 
latter;  (^)  diverticulum  after  it  has  been  everted  ("  evaginated  ")  and 
opened  with  a  longitudinal  incision.  Length,  9cm.;  circumference,  7.5 
cm.  Diameter  of  intestine  above  the  stenosis,  14.5  cm.;  below,  5cm. 
(From  "  Krankheiten  des  Darms  u.  des  Bauchfells,"  von  Prof.  Dr.  C. 
A.  Ewald.) 

diverticulum  and  thus  invaginating  its  own  wall.  In  a  few  in- 
stances the  process  was  acute  from  the  start.  In  either  case,  an 
accurate  diagnosis  is  impossible.     The  mode  in  which  this  ac- 


678 


THE    GASTRO-INTESTINAL    CLINIC 


cident  happens  is  shown  by  the  accompanying  diagram.     Fig. 
85  (a)  and  (b). 

The  secondary  intussusception  of  the  ileum  will  be  produced 
by  dragging  on  the  inverted  diverticulum,  and,  from  the  fact 


Fig.  85. — {a)  Ileum  with   Meckel's  diverticulum  before  invagination. 

/mmmmmmmmmm/ 


Fig.  85. — (d)  Meckel's  diverticulum  invaginated  into  the  ileum.  Dotted 
line  shows  position  of  invagination.  Arrows  indicate  direction  of 
peristalsis. 

tfiat  the  pull  is  exerted  on  one  side  of  the  ileum  only,  the  ring 
surrounding  this  secondary  intussusception  will  be  obliquely 
disposed  with  regard  to  the  circumference  of  the  bowel.  This 
is  best  explained  by  the  annexed  diagram  (Fig.  86). 

In  the  cases  in  which  the  process  is  connected  with  the  um- 
l)ilicus,  the  intussusception  takes  place  in  the  opposite  direc- 
tion toward  the  umbilicus.  Under  these  circumstances,  there 
are  three  different  accidents  which  may  occur:  (i)  The  di- 
verticulum may  be  telescoped  into  its  own  lumen,  as  is  shown 
in  the  figure  below  (Fig.  87). 

After  a  time  the  posterior  wall  of  the  ileum  (at  C)  may  be 
drawn  into  the  grasp  of  the  diverticulum  and  a  double  in- 
tussusception produced,  as  in  the  annexed  figure  (Fig.  88). 


INTESTINAL    OBSTRUCTION 


679 


Under  the  conditions  illustrated  in  Fig.  88  there  would  be  an 
umbilical  tumor,  from  the  center  of  which  feces  would  be 
extruded. 

(2)  The  second  case,  illustrated  in  Fig.  89  (a)  and  (b),  is 
one  in  which  the  first  part  of  the  prolapse  is  the  posterior  wall 


Fig.  86. — Secondary  intussusception  of  ileum  due  to  invaginated  divertic- 
ulum, B.  Place  where  wall  of  bowel  is  pulled  in,  forming  the  oblique 
constriction  ring  A,  B. 

of  the  ileum  and  when  this  intussusception  has  proceeded  far 
enough  the  diverticulum  may  telescope  into  its  own  lumen, 
producing  a  final  result  similar  to  that  in  which  the  starting 


VMB/L/CUS 


r^y^y///////^^^^^^^^^^^^^^^^^^ 


ABDOMINAL    WALL 


■if/y£ffr/cuL  (JA/ 


'(^///////////////////ym/y/ym, 


Fig.  87. — Meckel's  diverticulum  invaginated  into  its  own  lumen.    The  con- 
stricting line  is  showing  at  ^,  B. 

point  was  in  the  wall  of  the  patulous  process  and  the  posterior 
part  of  the  ileum  was  pulled  in  afterward. 

(3)  The  third  accident  which  may  occur  (shown  in  Fig.  90) 
is  that  an  invagination  may  begin  in  the  bowel  above  the  di- 
verticulum, and,  instead  of  passing  down  toward  the  ileocecal 
valve,  finds  its  way  to  the  umbilicus  by  way  of  the  open 
Meckel's  diverticulum. 


68o 


THE    GASTRO-INTESTINAL    CLINIC 


It  will  readily  be  seen  that,  under  these  conditions,  there  will 
be  at  first  a  few  bowel  movements,  and  later  none  at  all,  be- 
cause all  the  feces  will  be  sidetracked  in  the  direction  of  the 
arrow  A,  and  will  escape  at  the  umbilicus  from  the  center  of 


UMB/UCUff 


Fig.  88. — Meckel's  diverticulum  invaginated  into  its  own  lumen  and  pos- 
terior surface  of  ileum  also  invaginated  into  the  same.  The  line  A,  B, 
shows  the  lower  limit  of  the  intussuscipiens.  C,  Point  on  posterior 
surface  being  drawn  into  the  diverticulum. 

the  tumor.  As  in  other  instances,  this  intussusception  may- 
remain  single,  or  a  second  one  may  take  place,  implicating  the 
walls  of  the  diverticulum. 

Clinically  pathologic  states  of  Meckel's  diverticulum  are  not 
frequently  encountered ;  but  a  patulous  condition  of  the  process 
is  found  in  nearly  two  per  cent,  of  all  bodies  in  the  dissecting 
room. 

A  weak  constitution  with  flabby  muscles,  as  well  as  the 
presence  of  benign  tumors  or  polypi  in  the  intestine,  predispose 
to  the  production  of  intussusception. 

The  symptoms  of  intussusception  include  those  common  to 
UKjst  forms  of  acute  obstruction  already  described,  and  when 
the  obstruction  is  complete,  as  in  the  more  marked  invagina- 
tions, you  will  observe  the  symptoms  which  always  follow  a 
strangulation  of  a  portion  of  intestine  from  any  cause.  The 
patient  is  suddenly  seized  with  severe  pain  in  the  abdomen 
referred  generally  to  the  region  of  the  umbilicus,  or  when  the 


INTESTINAL    OBSTRUCTION 


68 1 


trouble  is  in  the  colon,  it  may  be  localized  at  first  at  the 
site  of  the  obstruction.  Almost  simultaneously  with  the  pain 
there  occurs  vomiting  which  is  a  reflex  from  the  traumatism, 

OMB/L/C/C/S' 

ABDOM/A/AL     WALL 


III   ,,  WZ^TZl 


Fig.  Sg  {a).— First  stage.     A,  Point  on  posterior  wall  of  ileum  where  in- 
vagination begins. 


Fig.  89  (b).— Second  stage.     A,  Point  on  posterior  wall  of  ileum  which  is 
now  protruding  from  the  umbilicus. 

and  thus  differs  from  that  which  results  later  in  the  disease 
from  an  accumulation  of  ingesta  and  secretions  in  the  ali- 
mentary canal  above  the  obstruction.  There  are  usually  evi- 
dences of  shock  in  the  rapid,  feeble  pulse,  clammy  skin,  and 


682 


THE    GASTRO-INTESTINAL    CLINIC 


anxious  facies.  Distention  of  the  intestines  above  develops 
more  rapidly  than  in  obturation,  obstruction,  or  even  in  peri- 
tisnitis. 

In  intussusception  there  is  often  tenesmus,  and  in  80  per 
cent,  of  all  cases  frequent  non-fecal  evacuations  containing  a 
little  blood,  with  also  generally  small  amounts  of  mucus,  or 


SBOWEL  PROTfiUO/NG 

fROM  aMBILfCUS 


ABDOMINAL    WALL 


Fig.  90. — Invagination   beginning   above   the   diverticulum.     Arrow,    C, 
shows  direction  of  intussusception;  A,  B,  line  of  constriction. 


more  frequently  merely  blood-tinged  mucus.  A  sausage- 
shaped  tumor  can  nearly  always  be  felt,  and  marked  indi- 
canuria  is  generally  present,  especially  when  the  small  intestine 
is  involved. 

Invaginations  of  the  colon,  which,  like  those  in  other  parts 
of  the  bowel,  are  most  frecjuent  in  children,  are  more  easily 
diagnosed,  as  well  as  treated,  than  those  of  the  small  intestine. 
Leaving  aside  those  which  begin  at  or  near  the  ileocecal  valve, 
they  are  usually  single.  They  most  commonly  contrast  with 
those  of  the  small  bowel  by  presenting  less  violent  symptoms, 
though  this  is  not  invariably  the  case.  The  places  at  which  the 
invagination  usually  happens  are  the  cecum  and  the  ascending 
and  descending  colon.  The  symptoms  do  not,  in  other  respects, 
differ  from  those  characteristic  of  the  disease  in  the  small  in- 
testine, except  that  indicanuria  is  much  less  pronounced,  as  a 
rule.    The  prolapsed  bowel  may  possibly  be  felt  in  the  rectum. 

The  treatment  of  intussusception  which  cannot  be  reached  by 


INTESTINAL    OBSTRUCTION  683 

inflation  through  the  rectum  is  purely  surgical,  and  it  is  safe 
to  say  that  it  is  impossible  without  operation  to  treat  success- 
fully any  intussusception  involving  the  ileocecal  valve,  or  which 
is  located  above  it. 

The  treatment  of  the  colic  form  of  intussusception  should 
include  the  withholding  of  all  food  by  the  mouth,  and  the  ad- 
ministration of  enough  opiates  to  inhibit  peristalsis.  The  sim- 
plest method  of  reduction  is  to  inflate  the  colon  with  filtered 
air  or  some  other  inert  gas.  To  do  this,  before  the  patient  is 
aneesthetized,  the  colon  is  flushM  with  about  a  gallon  of  water. 
The  patient  is  then  anaesthetized  and  held  with  the  feet  up  and 
the  head  down  in  as  nearly  as  possible  an  inverted  position. 
Inflation  with  the  gas  is  then  done  by  the  rectum  and  will  fre- 
quently reduce  the  intussusception  in  recent  cases  in  which  the 
difficulty  lies  entirely  below  the  ileocecal  valve.  It  is  not  al- 
ways safe  to  assume  that  it  is  so  situated  when  the  ascending 
colon  is  implicated,  since  many  colic  intussusceptions  are  sec- 
ondary to  enteric  invaginations.  If,  after  this  method  has  had 
a  reasonable  trial,  reduction  is  not  effected,  laparotomy  should 
be  done  without  delay.  Efforts  at  reduction  made  through  the 
incision  may  then  often  be  successful.  If  not,  either  an  in- 
testinal anastomosis,  an  enterostomy,  or  a  colostomy  should  be 
performed.  After  the  abdomen  has  been  opened,  reduction  by 
manual  traction  may  be  assisted  by  maintaining  the  inflation 
of  the  colon. 

Volvulus  is  due  to  the  twisting  of  a  segment  of  intestine 
upon  itself  or  around  a  neighboring  coil,  and  can  occur  only 
in  individuals  with  an  abnormally  long  or  relaxed  mesentery. 
It  involves  most  frequently  the  sigmoid  flexure — in  over  half 
of  all  cases. 

The  symptoms  of  volvulus  are  those  common  to  other  me- 
chanical forms  of  intestinal  obstruction  dependent  upon  stran- 
gulation. A  sign  which  is  held  by  Wahl  to  be  pathognomonic 
of  volvulus  is  the  presence,  during  the  first  day,  of  a  circum- 
scribed area  of  tympany  which  occurs  in  the  affected  segment 
of  the  bowel.    This  is  caused  by  distention  with  gas.    After  the 


684  THE    GASTRO-INTESTINAL    CLINIC 

first  twenty-four  hours  this  sign  is  difificult  to  recognize,  be- 
cause the  whole  abdomen  will  then  be  distended  and  tym- 
*panitic. 

The  treatment  of  volvulus  is  an  immediate  laparotomy.  The 
affected  loop  may  be  readily  untwisted  in  recent  cases ;  but  if 
the  bowel  shows  evidences  of  beginning  gangrene,  the  loop 
should  be  excised  and  an  intestinal  anastomosis  performed.  It 
is  frequently  well  to  take  a  tuck  in  the  mesentery  to  obviate 
the  return  of  the  volvulus. 

Hernia. — An  extended  discussion  of  hernias  is  out  of  place 
here ;  but  since  any  of  them  may  lead  to  intestinal  obstruc- 
tion, I  will  enumerate  the  varieties,  with  special  reference  to 
the  locations  in  which  you  should  seek  for  such  a  cause  in  any 
obscure  case.     The  chief  varieties  are : 

1.  Diaphragmatic,  in  which  the  viscus  is  protruded  through 
the  diaphragm,  usually  at  one  of  the  weak  points,  such  as  the 
crura  or  just  behind  the  sternum  where  the  costal  portion  joins 
the  sternal. 

2.  Umbilical,  in  which  there  will  usually  be  an  umbilical 
tumor.  A  hernia  into  a  patulous  Meckel's  diverticulum  is  a 
subvariety  of  this  class,  and  has  already  been  described. 

3.  Retroperitoneal. — This  form  of  hernia  occurs  in  the  fol- 
lowing places : 

(a)  Through  the  foramen  of  Winslow  passing  into  the 
lesser  sac.  (b)  Into  the  phrenico-hepatic  fossa  located  near 
the  left  lobe  of  the  liver,  (c)  A  series  of  three  fossae  which 
have  been  described  in  relation  with  the  ascending  limb  of  the 
duodenum  and  duodeno-jejunal  angle  (fossa  of  Treitz).  (d) 
An  intersigmoid.  (e)  Iliaco-subfascialis,  a  recess  in  relation 
with  the  left  psoas  minor  muscle.  (/)  Three  fossae  in  the 
neighborhood  of  the  cecum. 

4.  Through  slits  in  the  mesentery. 

5.  Inguinal,  escaping  through  the  inguinal  canal  to  present 
at  the  external  abdominal  ring.  This  variety  occurs  most  fre- 
quently in  males. 

6.  Femoral,  which  passes  along  the  femoral  canal  to  the 


INTESTINAL   OBSTRUCTION 


685 


inner  side  of  the  femoral  vessels  and  presents  on  the  thigh 
through  the  cribriform  fascia.  This  hernia  occurs  most  often 
in  women. 

7.  Obturator. — In  this  rather  uncommon  form  of  hernia, 
the  gut  protrudes  through  the  obturator  or  thyroid  foramen  of 
the. ileum.  In  its  passage  through  the  foramen  the  hernia  will 
press  upon  the  obturator  nerve  which  goes  to  supply  the  mus- 
cles and  integument  of  the  inner  side  of  the  thigh  as  far  as 
the  knee.  This  distribution  of  the  obturator  nerve  explains  the 
peculiar  symptom  of  this  hernia ;  /.  e.,  pain  at  the  inner  side  of 
the  knee. 

8.  Sacrosciatic,  a  rare  variety  in  which  the  viscus  pro- 
trudes through  the  sacrosciatic  foramen. 

The  symptoms  of  hernial  obstructions  are  those  typical  of 
strangulation  from  other  causes  which  are  described  below. 

Strangulation  of  the  Intestines  by  Knotting,  etc. — The 
bands  of  adhesion  produced  by  peritonitis  may  cause  obstruc- 
tion by  a  fixed  kinking  or  knotting,  or  in  other  ways  lead  to 
strangulation  of  loops  of  the  bowel. 
Such  bands  are  frequently  long, 
and  it  is  not  strange  that,  dur- 
ing active  peristalsis,  a  loop  of 
intestine  sometimes  becomes  tied 
or  otherwise  constricted  by  one 
of  them,  with  the  result  of  stop- 
ping at  once  both  the  passages  of 
feces  and  gases,  and  the  local  cir- 
culation in  the  part.  A  loop  of 
intestine  may  become  strangulated 
similarly  by  being  caught  behind 
the  appendix  or  a  fallopian  tube, 

when  the  free  end  of  these  has  been  attached  to  a  neighboring 
organ  by  adhesive  inflammation. 

The  Symptoms  of  Strangulation  Ileus. — In  such  accidents 
the  symptoms  are  likely  to  come  on  abruptly,  and  with  unusual 
violence.     They  have  been  so  graphically  described  by  Tu- 


FiG.  91. — Knotting  of  loops  of 
the  ileum, — (Leichtenstern,) 


686 


THE    GASTRO-INTESTINAL    CLINIC 


holske^  that  I  cannot  do  better  than  to  reproduce  here  his  ac- 
count of  them : 

"  Having  in  a  given  case  ehminated  the  probabihty  of 
paralytic  ileus,  and  decided  that  we  are  dealing  with  a  mechan- 
ical obstruction  not  congenital,  the  question  of  strangulation  or 
obturation  presents  itself.    The  paradigm,  as  mentioned  above, 


Fig.  92. — Constriction  of  a  loop  of  small  intestine  by  an  adhesion  at- 
tached to  the  omentum  at  both  ends.  (From  "  Krankheiten,  des  Darms 
u.  des  Bauchfells,"  von  Prof.  Dr.  C.  A.  Ewald.) 

of  a  strangulation  is  the  strangulated  external  hernia,  or  a 
strangulation  of  the  bowel  and  its  mesentery.  The  picture  of 
strangulation  is  a  striking  one.  A  person,  apparently  in  good 
health,  is  suddenly  taken  with  a  violent  pain  in  the  abdomen, 
accompanied  by  collapse,  nausea,  and  vomiting.  To  this  is 
very  soon  added  the  urgent  desire  to  relieve  the  bowel  of  feces 
and  flatus.     There  is  at  once  the  feeling  of  serious  illness,  of 

1  Loc.  cit. 


INTESTINAL    OBSTRUCTION  68/ 

great  anxiety  and  restlessness.  Unrelieved,  these  symptoms 
are  joined  by  that  of  intestinal  distention. 

"  The  pain  generally  felt  about  the  navel  is  not  significant 
of  locality;  it  is  infinitely  more  severe  in  the  thin,  highly  in- 
nervated small  intestine  than  in  the  large.  The  initial  vomit- 
ing with  singultus  is  reflex  and  begins  with  the  occurrence  of 
strangulation,  and  with  it  also  come  the  signs  of  collapse, 
the  incarceration  collapse,  and  almost  anuria  from  reduction 
of  the  arterial  pressure.  The  vomiting  in  later  stages  is  due 
to  distention  and  gas  accumulation,  the  stercorsemia  to  toxic 
absorption  or  septic  infection  after  permeability  of  the  intesti- 
nal wall  has  become  established. 

"  After  a  few  hours,  perhaps  eight  to  twelve,  the  results  of 
the  circulatory  interference  become  noticeable;  the  strangu- 
lated section  of  bowel  becomes  distended,  fixed,  and  paralyzed, 
and  in  favorable  subjects,  seen  early,  produces  asymmetry  of 
the  abdomen  and  can  be  made  out  by  inspection  and  palpation. 
The  afferent  loop  is  not  yet  appreciably  distended ;  peristalsis 
may  be  present.  All  symptoms  increase  in  severity.  To  the 
distention  of  the  strangulated  part  distention  of  the  proximal 
loops  is  added  and  general  greater  distention.  The  efferent 
intestine  has  been  emptied  of  fluid  and  gaseous  contents  and 
remains  collapsed.  To  the  initial  shock,  the  incarceration 
shock,  after  the  second  day  are  added  symptoms  of  permea- 
bility, due  to  a  changed  condition  of  the  gut  at  the  point  of 
strangulation,  and  symptoms  of  general  peritonitis  develop; 
the  vomiting  increases  in  frequency,  and  the  putrid  feculent 
intestinal  contents  are  emitted  by  regurgitation.  The  abdo- 
men is  tense  and  tender  on  pressure,  peristalsis  everywhere 
absent ;  to  the  signs  of  stercorsemia  are  added  those  of  septic 
infection. 

"  With  the  occurrence  of  gangrene  the  pain  grows  less,  and 
tlie  patient  enters  the  stage  of  lethal  collapse.  The  occurrence 
of  perforation  may  somewhat  modify  the  latter  symptoms. 
If  we  add  to  these  local  symptoms  those  of  the  general  condi- 
tion, the  rapid,  feeble,  compressible  pulse,  the  anxious  expres- 


688  THE    GASTRO-INTESTINAL    CLINIC 

sion  of  countenance,  the  pale  or  cyanotic  color,  the  sunken  eye, 
the  pointed  nose,  the  skin  cold,  clammy,  and  empty  of  blood, 
we  get  the  appalling  picture  characteristic  of  the  result  of 
sudden  strangulation." 

Treatment  of  Strangulation  Ileus. — In  the  great  majority 
of  these  cases  surgical  intervention  is  absolutely  necessary,  and 


Fig.  q3. — Various  forms  of  constriction  by  a  club-shaped  diverticulum. 
(After  Regnault-Beclard  and  Treves.) 

the  sooner  it  is  resorted  to  the  better  the  chances  of  a  favorable 
result.  The  mortality  from  abdominal  operations  is  enor- 
mously increased  by  every  day's  delay,  and  in  doubtful  cases 
you  should  have  a  competent  laparotomist  in  consultation  with 
you  at  the  start. 

In  hernias,  even  when  strangulated,  there  is  often  a  possi- 
bility of  reduction  by  taxis  and  the  inverted  position,  but  the 
former  is  itself  really  a  surgical  procedure.  It  needs  to  be 
carried  out  with  skill  as  well  as  the  utmost  gentleness,  and 
should  not  be  prolonged  beyond  ten  minutes,  as  a  rule,  when  it 
fails  within  that  time  to  relieve  the  strangulated  portion  of  in- 
testine. 

Above  all  do  not  administer  a  cathartic  by  the  mouth  in 
this,  or  indeed,  any  other  form  of  serious  intestinal  obstruc- 
tion, except  when  there  is  a  probability  that  it  depends  upon  a 
fecal  stasis.     No  food  should  be  given  by  the  mouth  (and  this 


INTESTINAL    OBSTRUCTION  689 

rule,  too,  holds  for  all  such  cases)  and  the  patient  should  be 
confined  strictly  to  bed.  Morphine  should  be  administered  in 
sufficient  doses  to  control  the  pain  and  effect  the  utmost  pos- 
sible relaxation.  Anaesthesia  by  ether  or  chloroform  will  often 
greatly  assist  manual  replacement,  but,  as  a  rule,  should  not  be 
produced  until  a  surgeon  is  at  hand  to  open  the  belly  if  found 
necessary.  An  ice  bag  should  be  applied  locally  over  the  af- 
fected region,  or,  in  some  instances,  a  hot  poultice  or  hot  wet 
compress  will  be  better. 

The  detailed  directions  for  carrying  out  taxis  will  be  found 
in  all  the  works  on  general  surgery,  and  would  be  out  of  place 
here. 

External  Tumors,  Displaced  Organs,  etc. — Cancers  and 
sarcomas,  as  well  as  the  benign  tumors  which  are  rare  in  these 
parts,  may  obstruct  the  bowel,  whether  they  are  attached  to  the 
inside  or  outside  of  the  intestinal  wall,  or  to  adjacent  viscera 
but  near  enough  to  encroach  upon  the  lumen  by  pressure.  Tu- 
mors within  the  bowel  are  considered  under  Obturator  Obstruc- 
tion. The  obstruction  produced  by  tumors  regardless  of  their 
situation  develops  comparatively  slowly,  and  by  the  time  it  is 
serious,  the  tumor  can  generally  be  felt  on  palpation.  Cancer 
is  the  commonest  tumor  of  the  intestines,  and  it  most  fre- 
quently causes  obstruction  by  a  gradual  infiltration  of  the 
bowel  wall  in  an  annular  form ;  but  such  carcinomatous  stric- 
tures are  discussed  under  Chronic  Intestinal  Obstruction. 

Displaced  organs  may  occasionally  produce  obstruction 
similar  in  character  to  that  caused  by  tumors  pressing  from 
without,  or  gall  stones  lodged  in  the  common  duct  may  do 
the  same  by  their  pressure  upon  the  intestine.  The  organs 
chiefly  at  fault  in  this  respect  are  the  uterus  and  kidneys. 
Retrodisplacements  of  the  uterus  which  are  frequently  associ- 
ated with  enlargement  may  cause  sufficient  pressure  upon  the 
lower  bowel  to  occasion  a  stubborn  constipation,  and  excep- 
tionally, such  a  condition  may  simulate  obstruction.  Asso- 
ciated with  a  displaced  uterus,  there  is  sometimes  found  an. 
ovary  which  has  prolapsed  into  the  pouch  of  Douglas.     Such 


690  THE    GASTRO-INTESTINAL    CLINIC 

ovaries  are  usually  abnormally  tender,  and  sometimes  give  rise 
to  almost  absolute  obstruction  by  reason  of  the  pain  which  is 
caused  by  every  effort  to  move  the  bowels. 

Movable  kidneys  quite  frequently  interfere  with  the  onward 
passage  of  the  feces  by  a  direct  pressure  upon  a  loop  of  intes- 
tine, but  such  pressure  is  likely  to  be  intermittent  rather  than 
constant,  so  that  constipation,  rather  than  permanent  obstruc- 
tion, results  as  a  rule. 

A  peculiar  form  of  chronic  constipation  dependent  upon 
conditions  affecting  .the  right  kidney  has  been  investigated  by 
W.  Arbuthnot  Lane.^  He  says,  "  my  attention  was  directed 
to  this  diminution  of  the  lumen,  particularly  of  the  hepatic 
flexure,  by  the  close  resemblance  of  the  symptoms  in  these 
cases  to  those 'of  renal  troubles,  whether  of  calculus  or  of  exces- 
sive mobility."  Upon  operating,  nothing  but  bands  of  ad- 
hesions between  the  colon  and  kidneys,  and  a  kink  at  the  he- 
patic flexure  of  the  colon,  were  found.  However,  when  these 
were  separated  the  cases  were  greatly,  improved.  The  patients 
who  did  not  improve  were  women  in  poor  physical  condition, 
whose  intestines  were  flaccid  and  plastic.  In  Lane's  opinion 
the  cause  of  these  adhesions  is  an  overloaded  and  distended 
cecum  and  colon  which  sets  up  enough  irritation  to  produce  the 
bands  which  bind  together  the  colon  and  kidney.  This  author 
advises  an  anastomosis  between  the  ileum  and  sigmoid  flexure, 
because  adhesions  may  re-form,  and  because  the  cecum  and 
colon  may  fail  to  regain  tone  in  spite  of  massage,  electricity, 
and  other  treatment. 

Symptoms  of  Ohstniction  from  External  Tumors,  Displaced 
Organs,  etc. — In  the  cases  of  ileus  coming  under  this  class,  the 
symptoms  generally  develop  slowly,  except  when  a  heavy  organ 
by  its  sudden  displacement  abruptly  and  completely  shuts  off 
the  lumen  of  the  intestine,  compressing  at  the  same  time,  pos- 
sibly, its  mesentery  so  that  the  local  circulation,  as  well  as  the 
passage  of  feces  and  gases,  is  interrupted.  In  these  latter  ac- 
cidents   the    symptoms    may    be    acute.     Malignant    growths 

'  The  Lancet,  January  2,  1904. 


INTESTINAL    OBSTRUCTION  69 1 

usually  cause  their  own  localized  pain,  which  may  complicate 
the  clinical  picture. 

Otherwise  these  will  appear  with  a  gradually  increasing 
severity,  as  in  the  case  of  tumors  encroaching  upon  the  bowel, 
or  intermittently,  as  occurs  more  frequently  in  the  case  of  pres- 
sure from  displaced  viscera,  such  symptoms  as  pain  from 
gaseous  distention,  excessive  eructations,  vomiting  of  ingesta, 
with  finally,  in  the  severer  cases  which  are  not  relieved,  the 
vomiting  of  fecal  matter  and  other  distressing  features  of  a 
stubborn  mechanical  obstruction. 

The  treatment  of  the  forms  of  ileus  just  described  must  be  in 
the  main  surgical,  though  position  and  certain  mechanical 
measures  may  do  much  for  the  relief  of  obstruction  due  to 
pressure  from  displaced  organs.  A  rest  cure  has  often  re- 
lieved, and  doubtless  sometimes  permanently  cured,  such  cases 
by  the  prolonged  change  from  the  vertical  to  a  horizontal  po- 
sition of  the  trunk ;  and  other  changes  of  position  may  suggest 
themselves  to  you  as  likely  to  relieve  individual  cases  of  pres- 
sure from  such  a  cause. 

In  Lecture  XL.  you  will  find  descriptions  of  a  method  by 
which  movable  kidneys  and  other  displaced  abdominal  organs 
can  usually  be  raised  up  and  held  in  place  with  the  help  of 
straps  of  adhesive  plaster. 

Obturator  Obstruction.  Gall  Stones,  Enteroliths,  etc. — 
Obstruction  caused  by  enteroliths,  gall  stones,  and  other  for- 
eign bodies  impacted  in  the  bowel  is  rarely  complete  in  the  be- 
ginning, and  the  circulation  is  less  injured. 

Enterdliths  are  ordinarily  larger  than  gall  stones.  The 
nucleus  of  them  is  usually  a  gall  stone  around  which  the  con- 
cretion is  built  up  in  successive  layers. 

Gall  stones  too  large  to  pass  through  the  gall  duct  some- 
times ulcerate  through  into  the  intestine.  They  may  cause 
i-ntestinal  obstruction  in  several  ways.  ( i )  Their  presence  in 
the  gall  bladder  may  set  up  inflammatory  processes  with  the 
production  of  bands  and  adhesions  which  press  upon  and 
obstruct  the  intestine.     (2)   They  may  diminish  the  lumen  of 


692  THE    GASTRO-INTESTINAL    CLINIC 

the  bowel  by  direct  pressure  on  the  duodenum,  when  large 
stones  become  lodged  in  the  common  duct.  (3)  They  may 
fotm  a  mechanical  obturator  after  they  have  escaped  from  the 
common  duct  into  the  lumen  of  the  bowel. 

The  Murphy  button  has  sometimes  caused  obstruction  in  the 
same  way,  and  so  have  frequently  various  foreign  bodies,  such 
as  buttons,  coins,  false  teeth,  etc.,  which  have  been  swallowed. 

Obstruction  by  zvorms,  hardened  feces,  etc.,  belong  under  the 
head  of  obturation.  Masses  of  dead  worms  killed  by  a  vermi- 
fuge may  produce  serious  obstruction,  especially  when  there 
has  been  a  previous  stricture  of  the  gut  at  any  point.  It  is 
rare,  except  under  similar  circumstances,  that  fecal  tumors 
cause  such  complete  obstruction  as  to  be  followed  by  alarming 
symptoms,  though  they  may  often  temporarily  interfere  with 
bowel  movements  before  they  can  be  softened  by  repeated  doses 
of  physic  or  by  irrigation  of  the  colon.  They  are  especially 
likely  to  do  this  in  cases  of  spastic  constipation.  (See  Lec- 
ture LXIX.) 

Polypi,  and  exceptionally  sarcomas  in  the  intestine,  may  also 
cause  obstruction  by  plugging  the  lumen ;  besides,  they  often 
aid  in  the  production  of  intussusception. 

The  symptoms  of  obturation  ileus  are  in  general  much 
milder  than  those  of  the  other  forms  of  mechanical  obstruc- 
tion— at  least  in  the  beginning.  Even  when  the  occlusion  is 
complete,  there  is  very  much  less  interference  with  the  circu- 
lation in  the  walls  of  the  gut,  and  none  at  all,  as  a  rule,  with 
that  of  the  mesentery.  There  is  also  comparatively  little  shock, 
and  in  consequence  the  initial  reflex  vomiting,  which  is  such  a 
distressing  feature  in  the  forms  of  ileus  due  to  the  various 
forms  of  strangulation,  may  be  absent  altogether,  or  if  present, 
is  less  severe.  The  initial  pain  may  also  be  slight.  When  the 
bowel  is  completely  plugged,  the  accumulation  of  its  contents, 
together  with  the  gases  from  fermentation,  soon  produces  dis- 
tention with  consequent  pain,  which  is  likely  to  be  paroxysmal 
or  constant  with  frequent  exacerbations,  and  vomiting,  which 
finally  in  unrelieved  cases  becomes  feculent. 


INTESTINAL    OBSTRUCTION  693 

The  Pathology  o£  Intestinal  Obstruction. — AMiatever  the 
cause  of  the  obstruction,  the  important  pathologic  changes  in 
the  intestine  will  comprise  a  great  distention  and  dilata- 
tion of  the  tube  above  and  its  collapse  below,  while  the  affected 
segment  will  show  first  a  stasis  of  the  circulation,  followed 
shortly  by  an  intense  degree  of  inflammation  with  often  ulcer- 
ation, which  may  perforate,  thus  leading  to  a  secondary  peri- 
tonitis. In  the  beginning  the  peristaltic  movements  are 
markedly  exaggerated  in  the  intestine  above  the  obstruction, 
but  the  overaction  is  soon  succeeded  by  exhaustion  and  paral- 
ysis. The  dilatation,  when  the  occluded  segment  is  in  the 
ileum  or  higher,  will  usually  affect  all  of  the  afferent  intestine 
and  the  stomach  as  well.  When  it  is  in  the  colon  the  dilata- 
tion will  at  first  be  limited  by  the  ileocecal  valve,  but  will 
eventually  pass  beyond  this  and  involve  the  small  intestines. 

Differential  Diagnosis  of  Acute  Ileus. — It  is  generally  com- 
paratively easy  to  decide  that  your  patient  is  suffering  from 
acute  obstruction.  The  clinical  picture  already  described  is 
too  striking  to  admit  of  any  mistake,  and  a  leucocytosis  of 
18,000  or  over  by  the  end  of  twenty- four  hours  will  confirm  the 
diagnosis.  It  is  exceedingly  difficult,  however,  in  many  cases 
to  determine  which  of  the  various  causes  has  produced  the 
trouble,  and  in  just  what  part  of  the  bowel  it  is  situated.  To 
arrive  at  such  a  pathologic  and  anatomic  diagnosis  would  not 
be  important  if  there  were  any  hopeful  medical  treatment  ap- 
propriate to  all  the  different  varieties,  or  if  it  were  the  approved 
practice  to  operate  at  once  in  every  case,  regardless  of  the 
cause.     But  neither  of  these  propositions  is  true. 

Suppose  you  have  been  called  to  a  case  of  acute  obstruction 
within  the  first  few  hours  and  find  the  usual  symptoms  of 
pain,  vomiting,  obstipation,  and  beginning  tympanites.  You 
will  at  once  examine  most  carefully  and  note  whether  there  be 
anywhere  a  special  loop  of  intestine  or  region  of  the  abdomen 
which  is  particularly  inflated.  Such  a  finding  would  point, 
first  of  all,  to  volvulus,  especially  if  it  were  in  the  situation  of 
the  sigmoid,  but  might  mean  intussusception  or  strangula- 


694  THE    GASTRO-INTESTINAL    CLINIC 

tion  from  any  cause,  particularly  if  the  onset  had  been  very 
sudden.  If  an  invagination  had  occurred,  you  would  usually 
be  able  to  feel  a  sausage-shaped  tumor  just  below  the  dis- 
tended loop.  If  no  such  tumor  were  palpable,  and  no  external 
hernia  were  discoverable,  you  would  think  of  strangulation 
by  a  band  or  diverticulum.  If  the  onset  had  been  sudden  and 
severe,  including  early  vomiting  as  well  as  pain,  and  within  the 
first  five  to  ten  hours  the  abdomen  were  already  becoming 
exquisitely  tender,  showing  peritonitis  to  be  developing,  you 
would  have  reason  for  strongly  suspecting  the  perforation  of 
an  ulcer  into  the  peritoneal  cavity,  and  that  a  dynamic  obstruc- 
tion had  resulted. 

If  tenderness  were  present  over  all  or  part  of  the  abdomen, 
and  this  and  pain  had  for  some  time  preceded  the  vomiting, 
you  would  think  of  a  peritonitis  produced  by  some  infection, 
such  as  an  extension  from  a  diseased  appendix  or  fallopian 
tube,  or  the  gradual  leakage  of  pus  from  an  abscess.  In  acute 
peritonitis  an  abnormally  high  temperature,  in  the  rectum  at 
least,  is  only  very  exceptionally  absent,  though  it  may  be  in 
some  very  grave  cases  in  which  there  is  great  exhaustion. 

If  the  patient  should  be  a  child  under  ten,  or  even  twenty 
years,  intussusception  would  be  the  most  probable  cause  of  a 
suddenly  developed  ileus,  and  next  after  this,  in  likelihood, 
would  be  hernia  or  obstruction  by  worms.  Twists,  kinkings, 
displacements,  and  strangulation  under  attached  diverticula  or 
peritoneal  bands  are  comparatively  rare  in  childhood. 

In  older  patients,  the  more  sudden  and  violent  the  onset  of 
ileus  the  greater  the  probability  that  the  cause  is  hernia,  or  else 
volvulus  or  some  other  form  of  strangulation  not  remediable 
except  by  surgery.  It  could,  however,  be  due  to  an  in- 
tussusception in  the  colon  which  might  possibly  be  reduced  by 
inversion  and  inflation  from  below.  If  so,  there  would  likely 
be  tenesmus,  and  you  would  probably  find  blood-tinged  mucus 
in  the  evacuations.  If  no  tumor  could  be  felt  and  no  external 
hernia  be  found,  you  should  infer  that  the  cause  was  probably 
one  of  those  conditions  requiring  surgical  intervention. 


INTESTINAL    OBSTRUCTION  695 

Indeed,  in  so  far  as  regards  the  more  threatening  cases 
which  have  had  a  sudden  and  violent  onset,  exchiding  those 
dependent  upon  perforation  ah'eady  referred  to  as  weh  as  in- 
carcerated or  strangulated  external  hernias,  which  can  gener- 
ally be  recognized  and  sometimes  relieved  by  taxis,  etc.,  the  only 
probable  condition  in  which,  as  a  rule,  anything  of  practical 
advantage  can  be  gained  by  determining  the  locality  of  the 
lesion  in  the  bowel  is  intussusception.  When  the  usual  sau- 
sage-shaped tumor  characteristic  of  such  a  lesion  can  be  felt, 
you  can  usually  decide  readily  whether  it  is  in  the  colon,  af- 
fording then  some  encouragement  for  a  trial  of  non-surgical 
measures,  or  in  the  small  intestines,  in  which  case,  if  the  in- 
verted position  should  fail  to  accomplish  anything,  there  would 
be  virtually  no  remedy  left  except  laparotomy.  Together  with 
a  palpable  tumor,  frequent  evacuations  containing  only  a  little 
blood  and  mucus  and  passed  usually  with  much  straining, 
would  be  diagnostic  of  intussusception  when  present  with  the 
symptoms  of  acute  obstruction ;  and  as  to  localizing  the  in- 
vagination, besides  the  situation  of  the  tumor,  the  amount  of 
warm  water  which  could  be  injected  and  retained  for  even  a 
few  minutes  in  the  colon  would  indicate  approximately  how 
far  up  in  it  the  obstruction  was. 

In  the  obturator  forms  of  ileus  it  is  important  to  make  the 
setiologic,  pathologic,  and  anatomic  diagnosis,  and  as  soon  as 
possible.  Many  such  cases  can  be  remedied  without  an  ab- 
dominal section,  and  the  results  of  operative  intervention  are 
very  much  better  when  done  very  early.  Obstruction  due  to 
plugging  by  gall  stones,  enteroliths,  foreign  bodies,  hard  fecal 
masses,  etc.,  is  seldom  complete  at  first,  and  for  this  reason  as 
well  as  because  of  the  fact  that  no  violence  has  been  done  to 
the  mesentery,  and  the  interference  with  the  local  circulation 
of  the  part  in  the  beginning  is  but  slight,  there  is  a  mildness  of 
the  early  symptoms  in  marked  contrast  to  those  of  the  forms 
dependent  upon  strangulation.  The  pain  is  usually  much  less 
intense,  and  is  not  accompanied  by  vomiting  at  first.  Some 
gas,  and  often  even  a  part  of  the  feces,  may  pass  the  obstruc- 


6q6  the  gastro-intestinal  clinic 

tion,  and  in  consequence  marked  distention  is  much  later  in 
developing. 

When  a  gall  stone  is  the  obturator,  whether  or  not  it  has 
been  enlarged  by  successive  accretions  into  an  enterolith,  the 
patient  will  generally  have  had  previous  attacks  of  hepatic 
colic  accompanied,  as  a  rule,  by  jaundice,  bile-stained  urine, 
fever,  etc.  There  will  also  be  often  a  persisting  tenderness  in 
the  region  of  the  gall  bladder. 

In  the  case  of  foreign  bodies,  there  will  generally  be  a 
history  showing  that  something  of  the  kind  has  been  swal- 
lowed, and  if  they  are  metallic  the  x-rays  will  reveal  their  sit- 
uation. When  a  fecal  mass  is  the-  offender,  there  will 
be  a  history  usually  of  a  long-standing  constipation  and 
symptoms  similar  to,  but  still  milder,  as  a  rule,  than  those 
that  may  follow  obturation  by  gall  stones,  foreign  bodies, 
etc. 

The  symptom  vomiting  in  obturation  ileus  calls  for  special 
consideration.  It  is  here  generally  a  late  manifestation,  but 
when  it  appears,  more  speedily  becomes  fecal  than  in  the  other 
forms.  The  reason  for  this  is  that,  in  the  more  violent  forms 
due  to  strangulation  and  characterized  by  initial  emesis,  the 
contents  of  the  stomach  and  bowel  above  the  obstruction  are 
so  completely  emptied  before  the  time  when  fecal  vomiting 
would  usually  set  in,  that  no  feces  have  been  made  and  there 
remains  little  out  of  \vhich  they  can  be  made.  Moreover,  in  the 
severer  forms,  death  often  occurs  before  there  has  been  time 
for  the  development  of  stercoraceous  vomiting. 

The  pain  in  the  obturation  ileus  is  not  only  less  violent,  but 
also  much  less  continuous.  In  fact  it  is  usually  rather  inter- 
mittent, resembling  somewhat  labor  pains,  being  intensified  at 
every  contraction  of  the  afferent  part  of  the  intestine.  There  is 
rarely  any  such  profound  shock  with  collapse  as  generally  ac- 
companies strangulation  ileus. 

The  following  table,  contributed  by  R.  Fitz  to  the  Transac- 
tions of  the  Congress  of  Physicians  and  Surgeons,  vol.  i., 
1888,  shows  the  percentage  of  each  of  the  more  prominent 


INTESTINAL    OBSTRUCTION 


697 


symptoms  which  occurred  in  the  several  varieties  of  ileus  in 
a  series  of  295  cases  of  acute  intestinal  obstruction : 


Strangu- 
lation 
Per  cent. 

Intussus- 
ception 
Per  cent. 

Twist 
Per  cent. 

Gall 

Stones 

Per  cent. 

Stricture 

or 

Tumor 

Per  cent. 

Pain 

Nausea  and  vomiting 

Fecal  vomiting  ,         .         .         . 

Tympanites         .... 

Tumor 

Visible  coils         .... 

82 
69 
47 
56 
10 
II 

70 
75 
13 
33 
69 

60 

37 
15 

55 

7 

83 
74 
61 
56 
13 

60 
80 

33 
66 

27 
20 

Ewald  makes  much  account  of  the  information  obtainable 
by  an  inflation  of  the  colon  with  air  or  any  inert  gas  or  the 
injection  of  water. 

Digital  examinations  per  rectum  and  vaginam,  as  well  as 
the  most  painstaking  palpation  of  the  abdomen,  will  help  to 
locate  obstructing  tumors  or  displaced  organs,  fecal  masses, 
twists,  intussusceptions,  etc. 

Finally  the  finding  of  marked  indicanuria  will  point  to  the 
small  intestines  as  the  probable  seat  of  the  obstruction,  though 
there  is  likely  to  be  a  moderate  excess  of  indican  present  in 
the  urine,  even  when  the  trouble  is  in  the  cecum  or  colon. 

The  Prognosis  of  Acute  Ileus. — Complete  occlusion  of  the 
intestines  is  a  very  serious  affection,  and  a  very  large  propor- 
tion of  all  the  cases  prove  fatal.  The  milder  cases  of  dynamic 
ileus,  some  of  which  scarcely  amount  to  acute  obstruction,  may 
be  temporary  in  character,  and  do  not  warrant  so  bad  a  prog- 
nosis, and  the  cases  due  to  a  local  peritonitis  are  very  generally 
rather  amenable  to  treatment,  either  medical  or  surgical.  Even 
the  severer  cases,  like  the  external  hernias  and  the  invagina- 
tions in  which  the  diagnosis  can  usually  be  made  early,  can 
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unfortunately,  either  the  attending  physician  or  the  family  in- 
sist upon  waiting  until  it  is  too  late.  In  the  internal  hernias, 
twists,  and  other  obscure  strangulations,  the  danger  is  greatly 
increased  by  the  obscurity  and  difficulty  in  making  a  certain 


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INTESTINAL    OBSTRUCTION  699 

diagnosis  at  the  only  time — in  the  early  stages — when  imme- 
diate laparotomy  affords  the  only  hope  of  cure. 

Obturation  ileus  has  generally  a  much  better  prognosis  than 
any  other  of  the  mechanical  forms.  The  onset  and  symptoms 
until  complete  occlusion  occurs  being  milder  and  the  course 
much  more  gradual,  there  is  a  better  opportunity  for  bringing 
to  bear  effective  treatment  at  an  early  stage. 

The  Treatment  of  Acute  Intestinal  Obstruction. — In  pre- 
vious sections  of  this  lecture  I  have  told  you  of  such  methods 
of  medical  treatment  as  give  some  promise  of  favorable  re- 
sults in  certain  varieties  of  acute  obstruction,  with  occasionally 
a  reference  to  the  surgical  operations  which  have  yielded  the 
best  results.  It  is  not  intended  in  this  work  to  instruct  you 
in  the  technique  of  any  such  operations.  Those  of  you  who 
do  your  own  abdominal  surgery  will  naturally  refer  to 
treatises  upon  that  subject,  and  the  others  should  call  in  a 
competent  laparotomist  early  in  every  case  of  acute  ileus. 

It  remains  to  be  said  concerning  the  medical  treatment  of 
acute  obstruction  that  the  patient  should  be  put  to  bed,  and  as 
perfect  rest  as  possible  secured  for  the  whole  body,  and  for 
the  functions  of  the  alimentary  canal  in  particular.  Allow  no 
food,  drink,  or  medicines  to  be  taken  into  the  stomach ;  but 
small  bits  of  ice  may  be  dissolved  in  the  mouth  as  often  as 
desired,  provided  the  water  be  not  swallowed.  The  mouth  and 
tongue  may  be  moistened  as  often  as  necessary  by  a  pledget 
of  cotton  or  sponge  wet  in  ice  water.  When  the  obstruction 
is  in  the  small  intestines,  half-pint  enemas  of  warm  (or  tepid) 
water  may  be,  from  time  to  time,  allowed  to  flow  into  the 
bowel  from  a  fountain  syringe,  placed  not  more  than  a  foot 
or  two  above  the  patient.  When  such  enemas  cannot  be  re- 
tained, fluid  must  be  supplied  to  the  system  by  injecting  a 
weak  saline  solution,  either  subcutaneously  or  into  a  vein. 

In  prolonged  cases,  provided  the  obstruction  be  not  in  the 
colon,  small  nutritive  enemas  may  be  given  several  times  a 
day. 

As  to  the  use  of  drugs:  in  the  first  place,  purgatives  must 


700  THE    GASTRO-INTESTINAL    CLINIC 

not  be  administered  either  by  mouth  or  rectum,  unless  other 
forms  of  obstruction  than  those  from  fecal  concretions  or 
mcisses  can  be  pretty  certainly  excluded.  They  may  pro- 
duce a  fatal  aggravation.  They  are  useful  in  fecal  obstruc- 
tion— dangerous  in  nearly  all  other  cases. 

Narcotic  medicines  are  indispensable  when  the  pain  is  very 
severe,  and  are  useful  also  to  quiet  excessive  and  harmful  peri- 
stalsis. Opium,  or  some  one  of  its  active  principles,  will  need 
to  be  administered,  either  by  suppository  or  hypodermically 
in  most  cases.  After  an  initial  dose  of  morphine  hypodermi- 
cally, extract  of  opium,  with  extract  of  belladonna  by  the 
rectum,  is  usually  sufficient.  Atropine  will  often  prove  a 
most  valuable  adjunct  to  the  opium,  and  has  a  still  more 
powerful  influence  in  the  relaxation  of  spasm.  With  every 
1-4  grain  of  morphine  injected  there  should  be,  in  these  cases, 
at  least  1-60  grain  of  atropine,  and  some  bold  therapeutists 
claim  to  have  obtained  brilliant  results  without  harmful  ef- 
fects from  such  extreme  doses  as  1-12  grain.  When  supposi- 
tories are  administered,  you  may  combine,  with  advantage. 
1-2  grain  of  extract  of  belladonna  with  every  grain  of  extract 
of  opium.  No  doubtful  case  of  acute  obstruction  should  be 
given  up  as  hopeless  until  the  effects  of  full  doses  of  bella- 
donna or  atropine  have  been  noted. 

\\'ashing  out  the  stomach  with  a  warm  saline  solution  is 
a  safe  procedure  in  nearly  all  cases  of  ileus,  and  will,  at  least, 
lessen  the  vomiting  by  removing  the  contents  of  the  viscus 
all  at  once.  Sometimes  it  is  reported  to  have  effected  almost 
magical  cures ;  but  my  own  experience  with  it  in  such  cases 
has  been  exactly  like  that  of  Ewald.  I  have  seen  it  improve 
all  the  symjitoms  for  a  time,  but  never  effect  by  itself  a  cure. 

The  administration  of  niefallic  mercury  is  no  longer  to  be 
recommended.  It  very  seldom  effects  any  good  results,  and 
in  certain  cases  could  easily  do  great  harm  by  increasing  an 
invagination,  twist,  or  strangulation.  In  the  cases  of  fecal 
obstruction  in  which  only  it  could  be  of  service,  we  have  better 
remedies  in  atropine  and  castor  oil,  or  the  saline  laxatives. 


INTESTINAL    OBSTRUCTION  /OI 

In  by  far  the  largest  number  of  all  cases  of  acute  obstruc- 
tion, laparotomy  is  the  only  hopeful  remedy,  and  little  time 
should  be  wasted  in  other  measures  in  very  severe  or  threaten- 
ing cases. 

CHRONIC  INTESTINAL  OBSTRUCTION— STENOSES 

Most  of  the  causes  of  ileus  above  described  may  at  times 
produce  incomplete  occlusion  only,  and  then  the  clinical  pic- 
ture is  likely  to  be  rather  that  of  chronic  than  of  acute  ob- 
struction. 

Chronic  Intussusception. — Invaginations  do  not  always 
close  the  lumen  of  the  gut  completely  and  then  assume  a 
chronic  form  with  occasional  acute  exacerbations.  Such  a 
condition  is  rather  misleading,  and  has  been  often  overlooked. 
In  such  cases  the  bowels  may  move  regularly,  with  or  without 
the  help  of  aperients,  and  are  often  loose.  There  is  much 
pain  which  is  usually  paroxysmal,  occurring  once  or  oftener 
daily,  though  sometimes  only  at  much  longer  intervals. 
Vomiting  is  rare,  but  the  typical  evacuations  of  blood-tinged 
mucus  will  be  passed  at  times,  especially  during  the  acute  ex- 
acerbations, and  during  the  latter,  too,  there  may  be  tenesmus. 
The  intussusception  is  oftenest  found  in  the  lowest  part  of  the 
ileum  (ileocolic),  but  any  part  of  the  large  or  small  intestine 
may  be  involved.  The  usual  sausage-shaped  tumor  can  be  felt 
in  over  half  the  cases. 

Strictures  from  Healed  Ulcers  and  Carcinoma. — A  ma- 
jority of  cases  of  intestinal  stenosis  are  probably  produced  by 
the  cicatrices  of  the  various  kinds  of  ulcers.  These  are  dis- 
cussed with  sufficient  fullness  in  Lectures  LV.  and  LVIII. 
Carcinoma  produces  stenoses  in  various  ways,  but  chiefly  by 
an  annular  infiltration  of  the  gut  which  gradually  thickens  the 
wall  by  an  infiltration  of  all  the  layers,  and  thus  lessens  the 
lumen.  Tumor  masses  ma}^  also  project  within  the  bowel  and 
lead  to  the  same  result. 

The  symptoms  of  carcinomatous  stenoses  include  the  pain 
characteristic  of  malignant  growths,  which  in  most  cases  is 


702 


THE    GASTRO-INTESTINAL    CLINIC 


Fig.  94.— Tuberculous  stricture  of  the  ileum.  Upper  figure  shows  hyper- 
trophy  and  atrophy  of  intestine  above  and  below  stricture.  Lower 
figure  shows  parts  removed  from  section  in  same  case;  a,  ulcer  at  site  of 
rent  in  colon  made  during  operation;  b,  fistula  bimucosa  between  ileum 
and  sigmoid  flexure;  c,  ileocecal  valve;  d,  mesenteric  band.  (From  a 
paper  on  Enterostomy  for  Tuberculous  Stricture  of  the  Intestine,  by 
f.  M.  Caird,  F.  R.  C.  S.,  in  ScoL  Med.  and  Surg-,  four.,  vol.  xiv.,  No.  i,; 


INTESTINAL    OBSTRUCTION 


703 


rather  persistent,  though  rarely  very  severe,  and  may  be  ab- 
sent.    In  addition  there  are,   as  a  rule,  the  other  symptoms  of 


Fig.  95. — Colloid  cancer  and  tubercle.  Figure  to  right,  posterior 
view  of  cecum,  etc.,  a,  ileocecal  valve;  b,  appendix.  Upper  left 
figure  from  same  case,  portion  of  small  intestine  with  patch  of 
colloid  cancer.  Lower  left  figure,  the  same  in  section.  (From  a  paper 
on  Enterostomy  for  Tuberculous  Stricture  of  the  Intestine,  by  F.  M. 
Caird,  F.  R.  C.  S. ,  in  Scot.  Med.  and  Surg,  four.,  vol.  xiv.,  No.  i.) 


such  a  growth — anaemia    and  generally  in  time  a  cachexia, 
debility,  emaciation,  and  disturbances  of  the  digestion.     As  a 


704 


THE    GASTRO-INTESTINAL    CLINIC 


Pig.  96.— Tuberculous  stricture  of  the  ileum.  Upper  left  figure  shows 
great  dilatation  above  stricture  and  tuberculous  deposits  tending  to 
form  strictures.  Lower  left  figure  from  same  case.  Remote  lower 
stricture.  Figure  to  right  from  another  case,  marked  dilatation  of  part 
above  stricture.  (From  a  paper  on  Enterostomy  for  Tuberculous 
Stricture  of  the  Intestines,  by  F.  M.  Caird,  F.  R.  C.  S.,  in  Scot.  Med.  and 
Surg.  Jour.,  vol.  xiv.,  No.  2,) 


INTESTINAL    OBSTRUCTION  705 

result  of  both  the  decreasing  motihty  of  the  intestinal  muscle 
above  the  affected  part,  and.  of  the  slowly  narrowing  stric- 
ture, constipation  and  meteorism  gradually  develop.  Finally, 
especially  when  the  stricture  is  in  the  lower  part  of  the  canal, 
some  time  before  the  tumor  has  shut  off  entirely  the  lumen  of 
the  bowel,  feces  accumulate  in  the  dilated  loop  above  and  set 
up  the  symptoms  of  acute  obstruction.  Such  acute  attacks 
may  be  overcome  and  recur  repeatedly  before  the  lethal  end 
comes,  except  when  there  has  been  surgical  intervention. 

Tubercular  Ulcers  and  Growths  as  Causes  o£  Chronic  Ob- 
struction.— Tuberculosis  may  obstruct  the  intestines  both  by 
the  contraction  of  the  scars  of  healed  tubercular  ulcers,  and  by 
the  formation  of  tumor-like  masses  within  and  around  them, 
through  a  process  of  infiltration,  or  fibrous  hyperplasia.  An- 
nular constrictions  similar  to  those  of  cancer  also  occur. 

The  cecum  and  lower  ileum  are  most  frequently  involved. 
In  six  out  of  eleven  cases  reported  by  Caird^  the  ileocecal 
valve  and  cecum  were  affected,  and  the  appendix  was  com- 
pletely hidden  in  the  mass  of  proliferated  tissue.  In  four  of 
the  same  series  of  cases,  the  small  intestine  only  was  impli- 
cated.    (See  illustrations  on  pages  702-704.) 

In  Caird's  cases  the  symptoms  had  been  little  marked  at 
first,  as  in  nearly  all  instances  of  intestinal  stenosis  from  a 
cause  which  only  gradually  develops,  though  generally  he  has 
been  able  to  obtain  a  personal  and  family  history  of  tubercle. 
There  is  usually  a  history  of  failing  health  for  years,  with  in- 
digestion, colicky  pain,  tenderness  on  pressure,  and  constipa- 
tion. Vomiting  is  frequent  and  generally  relieves  the  pain,  but 
no  blood  is  brought  up.  Caird  particularly  calls  attention  to 
the  presence  in  nearly  all  the  cases  of  loud  borborygmi.  He 
has  been  able  to  palpate  a  tumor  in  the  ileocecal  cases,  and  re- 
ports that  he  has  not  often  noted  complete  obstruction,  except 
when  the  stricture  has  been  blocked  by  some  foreign  body. 

As  in  other  strictures  of  the  intestine,  serious  symptoms  of 

'  Scot.  Med.  and  Surg.  Jour.,  vol.  xiv.,  No.  2. 


706  THE    GASTRO-INTESTINAL    CLINIC 

increasing  meteorism,  pain,  emaciation,  exhaustion,  etc.,  de- 
velop finally,  even  before  the  stricture  has  caused  complete 
occlusion. 

As  to  treatment,  surgery  affords  the  only  effective  resource, 
and  Caird  reports  that  out  of  his  eleven  cases,  seven  were  cured 
by  enterectomy. 


LECTURE  LXV 

ACUTE    CATARRH    OF    THE    INTESTINES 
(ENTERITIS  ACUTA) 

This  is  deemed  by  some  authors  the  most  frequent  disease 
of  the  bowels ;  but  the  chronic  form  of  intestinal  catarrh,  in- 
volving the  small  intestine  and  having  constipation  as  its  main 
symptom,  is  probably  still  more  prevalent,  though  very  often 
overlooked. 

Acute  enteric  catarrh  may  affect  the  entire  gut  at  once,  or 
be  limited  to  any  part  of  it.  When  its  chief  seat  is  the  upper 
part  of  the  small  intestine  (especially  the  duodenum),  catarrh 
of  the  stomach  almost  always  coexists,  and  vice  versa.  The 
colon  alone,  or  any  part  of  it,  may  be  affected,  especially  the 
cecum  or  the  rectum,  without  the  involvement  of  the  small 
intestine,  but,  according  to  Nothnagel,  it  is  very  unusual  for 
the  ileum  to  be  the  seat  of  a  catarrhal  process  without  the 
colon's  being  also  to  some  extent  implicated. 

.ffitiology — A  most  important  light  has  been  shed  upon 
intestinal  diseases  through  the  recent  exact  studies  of  the  di- 
gestive system.  It  has  been  shown  that  the  secretion  of  HCl 
in  the  stomach  is  very  frequently  excessive,  and  it  is  probable 
that  when  this  continues  in  high  degree  for  a  long  time,  the 
mucous  membrane  of  the  upper  intestine,  that  of  the  duodenum 
especially,  may  become  irritated  and  finally  involved  in  a 
catarrhal  process.  It  has  been  noted,  too,  by  many  observers, 
that  long-standing  cases  of  hyperchlorhydria  are  often  asso- 
ciated with  constipation,  which  seems  to  be  a  result,  being 
often  relieved  when  the  HCl  excess  has  been  overcome.  And 
constipation  is  a  frequent  cause  of  enteric  catarrh  in  both  its 
acute  and  chronic  form.     It  has  been  observed  also,  by  Allen 

707 


708  THE    GASTRO-INTESTINAL    CLINIC 

Jones  and  others,  that  a  very  low  or  absent  gastric  secretion  is 
o^ten  apparently  a  direct  cause  of  diarrhea.  In  stubborn  in- 
testinal catarrhs,  therefore,  it  is  very  important  to  know  the 
state  of  the  gastric  secretion,  and  to  correct  it  when  abnormal. 
Acute  enteritis  is  sometimes  caused  by  corrosive  poisons,  es- 
pecially overdoses,  or  the  too  frequent  repetition  of  purga- 
tives. In  persons  predisposed  to  such  attacks,  cold  may  be  the 
cause;  especially  prolonged  exposure  to  wet  and  cold.  Drink- 
ing freely  of  ice  water  sometimes  excites  an  attack,  but  by  far 
the  most  common  causes  of  the  affection  are  infection  from 
spoiled  or  decomposed  food  and  the  irritation  from  indigest- 
ible, or  at  least  undigested,  aliments.  This  may  result  from  an 
improper  kind  of  food,  as  well  as  from  too  hot  or  too  cold 
ingesta,  or  an  excess  of  proper  food ;  also  from  eating  when, 
on  account  of  either  great  fatigue,  overheating,  or  powerful 
emotions,  the  usual  digestive  processes  are  interfered  with. 
Burns  over  the  abdomen  may  also  set  up  a  catarrh,  or  even 
acute  ulceration  in  the  intestines.  Malarial  infection,  tuber- 
culosis, typhoid  fever,  and  other  diseases  may  be  accompanied 
by  a  secondary  acute  enteritis. 

Pathology. — Acute  enteritis  may  pathologically  assume  at 
least  three  different  forms — mucous,  mucopurulent  or  purulent, 
and  pseudomembranous.  There  are  redness,  either  diffused  or 
in  patches,  swelling  of  the  mucosa, — in  severer  cases,  of  the 
submucosa  also, — and  increased  secretion  which  is  usually 
mucoid,  but  when  the  inflammation  is  very  high,  may  become 
purulent.  The  membrane  is  covered  with  slimy  mucus,  and 
the  blood-vessels  are  injected — dilated. 

The  solitary  follicles  in  certain  of  the  cases  are  swollen  and 
prominent,  projecting  above  the  level  of  the  mucosa.  In 
other  cases  patches  of  the  mucosa  become  loosened  and  des- 
quamate. 

In  the  intenser  types  there  is  a  large  emigration  of  leuco- 
cytes, and  the  surface  of  the  mucosa  may  be  covered  with  pus. 
Extravasations  of  blood  may  also  occur  in  places.  A  round- 
cell   infiltration   takes  place   in   the   mucosa    and   submucosa. 


ACUTE    CATARRH    OF    THE    INTESTINES  /OQ 

Follicular  ulceration  often  develops  from  the  swelling  and 
bursting  of  the  solitary  follicles. 

In  the  pseudomembranous  type,  the  mucus  exuded  is  of  a 
tougher  and  more  plastic  nature,  so  that  patches,  strings,  or 
large  masses  form — sometimes  true  casts  of  portions  of  the 
intestine.  The  latter  cases  are  usually  characterized  by  con- 
stipation instead  of  diarrhea,  as  in  the  ordinary  acute  catarrhal 
cases.  Membranous  enteritis  does  not  often  occur  in  an  acute 
form,  but  is  generally  a  subacute  or  chronic  process.  See 
Lecture  LXXIII.  on  Membranous  Catarrh  of  the  Intestines. 

Symptomatology.— Diarrhea  is  the  predominant  symptom 
of  acute  intestinal  catarrh,  and  probably  occurs  in  all  cases, 
with  the  exception  of  those  in  which  the  process  affects  the 
stomach  and  duodenum  only.  It  usually  comes  on  suddenly, 
the  stools  to  the  number  of  three  to  six,  or  even  exceptionally 
ten  to  twenty  in  the  twenty-four  hours,  being  at  first  semi- 
solid, then  mushy,  and  later  gruel-like,  dark,  offensive,  and 
mixed  with  firmer  masses  or  scybala,  but  still  later  almost 
odorless,  of  a  pale  yellow  or  grayish  color,  and  containing 
considerable  cjuantities  of  mucus.  In  young  infants  the  stools 
are  often  green.  Pains  in  the  bowels,  often  severe  and  colicky, 
generally  precede  the  attack,  and  often  recur  with  each  stool. 
Tenesmus  points  to  involvem.ent  of  the  rectum.  In  typical 
cases  there  are  gaseous  rumblings,  a  vague  sense  of  general 
discomfort,  and  very  frequently  nausea  at  first,  which  may  go 
on  to  vomiting,  especially  when  the  attack  has  been  due  to  im- 
prudence in  diet  with  an  overloading  of  the  stomach ;  also  when 
the  appendix  is  involved  in  the  acute  catarrhal  process. 

Early  in  an  attack,  or  even  after  several  days  in  cases 
wrongly  treated  by  astringents  and  opiates  before  a  thorough 
emptying  of  the  bowel,  percussion  may  reveal  accumulations 
of  feces  in  the  cecum,  flexures  of  the  colon,  the  prolapsed 
center  of  the  transverse  colon,  or  in  the  sigmoid  flexure,  and 
nearby  or  above  such  obstructing  accumulations,  areas  of  tym- 
pany may  be  found. 

Sudden  tapping  with  the  finger  tips  in  the  same  region  often 


7IO  THE    GASTRO-IXTESTIXAL    CLIXIC 

causes  high-pitched  splashing  sounds  due  to  the  presence  of 
liquid  feces  and  gases.  Digital  exploration  may  discover  hard 
fecal  masses  in  the  rectum,  especially  in  cases  where  neglected 
constipation  has  been  a  cause  of  the  enteritis.  Deep  palpation 
frequently  produces  pain  over  the  course  of  the  colon,  when  this 
part  of  the  bowel  is  much  involved.  This  sign,  together  with  a 
larger  amount  of  free  mucus  with  the  stools,  will  help  you  to 
differentiate  a  colitis  from  inflammation  of  the  small  intestine 
only.  Boas  is  authority  for  the  statement  that,  in  colitis, 
bilirubin  cannot  be  recognized  in  the  stools,  having  been  con- 
verted into  urobilin. 

AMien  the  stools  contain  much  undigested  matter  with  com- 
parativeh'  little  mucus,  and  this  finely  divided  as  well  as  in- 
timately mixed  with  the  feces,  the  catarrh  aft'ects  the  small 
intestine  mainly.  In  the  same  condition  the  microscope  will 
reveal  many  undigested  muscle  fi-bers,  fat  globules,  and  starch 
granules. 

The  chemical  reaction  of  the  feces  in  enteritis  varies  widely. 
At  present  it  affords  no  certain  trustworthy  guide,  except 
that  when  there  is  excessive  acidity  alkaline  astringents,  such 
as  the  preparations  of  lime,  should  be  included  among  the 
remedies  prescribed. 

Some  rise  of  temperature  is  a  usual  accompaniment  in 
marked  cases,  especially  those  due  to  infection.  Fever  is  nearly 
always  present  when  the  patient  is  an  infant  or  young  child, 
but  is  less  constantly  seen  in  older  patients.  Various  degrees 
of  exhaustion  and  nervous  derangement  may  result,  the  form 
and  severity  of  such  phenomena  depending  upon  the  age,  tem- 
perament, and  previous  strength  of  the  patient.  The  urine 
becomes  scanty,  high-colored,  and  often  loaded  with  indican. 
Albumin  and  even  hyalin  and  blood  casts  may  also  appear  in 
the  urine  during  the  attack,  disappearing  after  convalescence. 

Diagnosis. — Primary  acute  enteritis  does  not  closely  re- 
semble any  other  affection.  Cholera  morbus  and  cholera  in- 
fantum, which  may  be  considered  as  merely  violent  forms  of 
acute  gastro-enteritis,  produced  by  an  uncommonly  severe  in- 


ACUTE    CATARRH    OF   THE   INTESTINES  7 II 

fection,  are  easily  differentiated  by  the  early  and  severe  gastric 
symptoms,  their  more  rapid  and  violent  course,  including  the 
earlv  serious  prostration,  and  wasting  and  pronounced  and 
very  painful  cramps.  It  would  not  be  possible  to  diegnosti- 
cate  from  simple  acute  enteritis  the  precursory  diarrhea  of 
Asiatic  cholera,  but  later  the  rice-water  stools  containing  the 
comma  bacillus  would  be  decisive. 

Serous  diarrhea  from  nervous  causes  is  recognizable  by  the 
character  of  the  stools  and  the  absence  of  all  inflammatory 
symptoms,  including  mucus  in  the  stools  and  tender  spots 
over  the  abdomen. 

Prognosis. — Uncomplicated  acute  intestinal  catarrh  is  rarely 
fatal,  except  in  infants  under  three  years,  and  even  in  the 
latter  is  nearly  always  curable,  provided  the  child  can  be  kept 
under  the  best  possible  hygienic  conditions,  removed  to  the 
seashore  or  mountains,  when  the  attack  occurs  in  hot  weather, 
and  have  a  suitable  diet,  including  good  breast  milk  for  those 
not  yet  weaned,  or  fresh  cow's  or  goat's  milk,  properly  modi- 
fied and  combined,  for  the  older  ones. 

In  very  old  or  debilitated  persons,  too,  the  affection  is  some- 
times fatal,  but  generally  because  of  incurable  disease  in  the 
stomach,  heart,  liver,  lungs,  or  kidneys,  of  which  it  is  merely 
a  complication. 

Treatment. — In  no  acute  disease  is  the  proper  treatment 
simpler  or  more  uniformly  successful  than  in  acute  enteritis  in 
adults  or  in  children  over  three  or  four  years  old ;  and  yet 
probably  none  is  oftener  wrongly  treated.  The  indications  are 
first  to  remove  promptly  and  thoroughly  the  noxious  cause, 
instead  of  waiting  for  nature's  slow  efforts  to  accomplish  this 
by  diarrhea,  and  next  to  give  as  complete  rest  as  possible  to  the 
temporarily  crippled  digestive  system.  When  you  have  se- 
cured these  two  conditions,  nature  will  quickly  effect  a  cure 
in  the  great  majority  of  cases  without  other  aid.  Elimina- 
tion and  functional  rest  then  constitute  the  keynote  of  the 
treatment;  and  in  febrile  cases,  rest  in  bed  should  be  en- 
forced.    The  emptying  of  the  alimentary  canal  can  generally 


712  THE    GASTRO-INTESTINAL    CLINIC 

best  be  accomplished  by  some  gentle  laxative,  though  if  the 
symptoms  are  urgent,  as  when  there  is  high  fever  or  convul- 
sions, or  other  serious  nervous  complications,  pointing  to  grave 
auto-intoxication,  you  should  also  cleanse  the  colon  at  once  by  a 
copious  irrigation  with  a  warm  saline  solution  to  which  some 
antiseptic  may  be  added.  For  the  laxative,  a  saline  or  castor 
oil  in  not  too  large  a  dose  (say  one  to  four  teaspoonfuls  of  the 
latter)  usually  proves  efficient,  but  no  single  remedy  acts  so 
magically  as  a  mild  mercurial  purge,  preferably  calomel  in  the 
dose  of  1-20  to  1-6  of  a  grain,  according  to  the  age,  mixed 
with  a  grain  of  sugar  of  milk  and  repeated  every  half  hour, 
until  a  favorable  change  of  color  appears  in  the  stools.  Not 
more  than  six  to  ten  doses  should  be  needed  to  restore  the 
normal  dark  yellow  color,  or  at  least  a  rich  golden  yellow 
showing  an  increased  content  of  bile,  and  at  the  same  time  to 
remove  in  a  few  hours  all  the  worst  symptoms.  I  will  not  at- 
tempt here  to  answer  the  objections  which  have  been  urged 
against  this  remedy,  nor  to  speculate  as  to  how  small  doses 
of  calomel  accomplish  such  strikingly  good  results.  It  is  suf- 
ficient to  emphasize  the  often  observed  clinical  fact  that  the 
remedy  will  cure  rapidly,  pleasantly,  and  harmlessly  in  most  of 
these  cases,  provided  at  the  same  time  the  digestive  system  is 
allowed  to  rest,  the  food  being  either  wholly  stopped  for  a 
day  or  two,  or  (when  this  is  impracticable)  limited  to  the 
lightest  possible  articles,  such  as  a  few  spoonfuls  at  a  time  of 
toast  water,  egg  water,  or  rice  water''  in  babies,  and  very 
small  feedings  in  adults  of  wine  whey  or  the  weakest  broths. 
If  by  the  second  day,  with  such  a  treatment,  the  patient  is  not 
well,  or  so  nearly  so  that  manifestly  nothing  further  is  needed 
beyond  a  day  or  two  more  of  functional  rest  through  a  severely 
restricted  diet,  you  may  administer  one-half  the  former  dose 
of  calomel  every  two  or  three  hours  for  one  day  longer.  If 
there  should  then  be  still  a  tendency  toward  diarrhea,  it  would 
indicate  either  an  exceptionally  severe  infection,  or  that  there 
had  been  ])reviously  a  chronic  catarrh,  involving  portions  of 
the  intestines,  and  often  the  stomach  as  well.     This  chronic 


ACUTE    CATARRH    OF    THE    INTESTINES  713 

process  after  the  subsidence  of  the  acute  attack  would  prevent 
an  early  return  to  normal  conditions  and  demand  further  treat- 
ment. Some  one  of  the  bismuth  preparations,  given  in  a 
simple  mixture  of  mint  water  and  limewater  after  every  stool, 
should  then  prove  efficient  in  controlling  the  remains  of  the 
diarrhea.     The  following  formula  usually  does  well : 

I^  Bismuth  subnitrat 3  i" 

Tannalbin 3  v 

Mist,  cretse,  q.  s.  ad f  §  iv 

■     M.  Sig. :  One-half  to  two  teapoonfuls,  according  to  age,  after 
every  loose  stool. 

When  much  pain  or  frecjuent  loose  movements  persist,  as 
will  very  rarely  happen  if  the  above-mentioned  plan  is  carried 
out  in  its  entirety,  the  foregoing  prescription  may  prove  more 
rapidly  effective  with  a  few  drops  of  paregoric  or  deodorized 
tincture  of  opium  added  to  each  dose.  ■ 

Another  good  formula  for  stubborn  cases  is  the  following: 

I^  Ichthalbin  )  aa  '^  ii 

Tannalbin  ) 

M.  et  ft.  chart  No.  XV. 

Sig.:  One  to  two  powders  in  milk  or  water  upon  arising,  at  bed- 
time, and  after  each  loose  stool. 

Remember  especially  that  during. the  first  day  or  two  the 
important  thing  is  to  assist  nature  in  clearing  out  the  alimen- 
tary canal,  and  to  spare  the  digestive  organs  by  allowing  the 
smallest  possible'  amount  of  nutriment.  To  give  an  astrin- 
gent before  the  bowels  have  been  thoroughly  emptied  is  never 
useful  or  justifiable,  but  always  harmful  and  sometimes  dis- 
astrous. The  early  use  of  opiates  should  be  equally  avoided, 
except  in  the  presence  of  intolerable  pain,  and  even  then  a 
further  gentle  use  of  laxatives  in  addition  to  antacids,  com- 
bined if  need  be  with  an  antispasmodic,  such  as  the  annexed 
prescription  calls  for,  is  generally  all-sufficient  and  far  safer: 

IJ  Tr.  Cardam.  comp ^ f  3  iv 

Sps.  ammon.  arom f  3  m 

Sps.  chloroform,  q.  s.  ad f  3  xii 

M.  Sig.:  Teaspoonful  in  half-glass  of  hot  water  every  hour  or 
two  till  relief. 


714  THE    GASTRO-INTESTINAL    CLINIC 

When  the  colon  is  solely  or  chiefly  involved,  cleansing  from 
below  by  irrigations  with  saline,  soothing,  and  antiseptic  solu- 
tions sometimes  offers  advantages,  especially  in  proctitis, 
though  in  chronic  colitis  these  local  measures  play  a  more  im- 
portant role  than  in  the  acute  form.  In  simple  acute,  non- 
dysenteric  colitis,  rest  of  the  whole  body  by  confinement  to 
bed  and  rest,  especially  of  the  digestive  organs,  with  elimina- 
tion by  laxatives,  will  usually  cure  within  a  few  days. 

The  diet  for  the  exceptional  cases  that  linger  on  longer,  in 
spite  of  the  treatment  above  laid  down,  should  comprise, 
mainly,  thoroughly  fresh  milk  boiled  and  mixed  with  lime- 
water  or  peptonized  and,  in  the  case  of  children,  properly  di- 
luted and  modified  to  approximate  it  to  human  milk,  fresh 
beef  juice  pressed  out  of  a  broiled  steak,  soft-boiled  or  poached 
eggs,  or  egg  water  for  children,  Eskay's  Food,  or  Plasmon, 
Bovinine,  whey,  kumyss,  and  later  chopped  beef,  toasted  bread, 
zwieback,  boiled  rice,  and  the  best  of  the  various  biscuits 
(crackers)  on  the  market,  provided  they  are  fresh.  The  bis- 
cuits sold  in  the  shops  are  often  many  months  old.  All  the 
vegetables  and  fruits  should  be  avoided.  Should  the  gastric 
juice  be  found  defi^::;nt,  HCl  and  pepsin  may  be  given,  es- 
pecially when  the  diet  is  increased.  In  the  cases  in  which  there 
is  an  absence  of  gastric  secretion,  with  atrophy  of  the  glands, 
the  preparations  of  pancreas  may  be  administered  hopefully 
with  or  after  food.  When  the  HCl  secretion  is  excessive,  on 
the  other  hand,  the  preparations  of  chalk  and  bismuth  should 
be  administered  with  nitrate  of  silver  and,  if  need  be,  bella- 
donna, but,  as  a  rule,  not  opium,  which  tends  usually  to  increase 
the  secretion. 

Let  me  repeat  in  closing,  ( i )  that  in  the  early  stages  of  any 
acute  inflammatory  or  infectious  diarrhea,  astringents  are  al- 
ways, and  opiates  generally,  useless  and  harmful;  and  (2) 
that  with  the  proper  treatment  by  rest  and  elimination  in  the 
first  stage,  there  will  rarely  ever  be  any  second  stage  to  treat. 


LECTURE  LXVI 

CHRONIC  CATARRH  OF  THE  INTES- 
TINES   (ENTERITIS  CHRONICA) 

Probably  no  disease  affecting  the  digestive  system,  except 
the  derangements  of  gastric  secretion,  is  more  prevalent  than 
the  chronic  form  of  intestinal  catarrh.  It  is  very  often  over- 
looked, the  victims  being  treated  for  the  associated  neuras- 
thenia, which  in  some  cases  may  be  the  cause,  and  in  many 
others  is  certainly  a  consequence.  The  only  symptoms  of 
certain  mild  cases  are  often  nervous  derangements,  and  in  the 
earlier  stages  of  the  less  severe  cases  there  may  be  absolutely 
no  symptoms,  except  usually  some  sluggishness  of  the  bowels. 

.ffitiology. — Some  of  the  causes  which  provoke  acute  catarrh 
of  the  intestines  also  tend  to  produce  the  chronic  form.  These 
include  improper  diet,  and  especially  overeating,  insufficient 
exercise  of  the  abdominal  muscles,  enteroptosis,  constipation, 
the  abuse  of  purgatives,  and  a  prolonged  excessive  secretion 
of  the  gastric  juice  (hyperchlorhydria)  among  other  setiologic 
factors.  It  is  probable  that  in  persons  with  an  inherited  tend- 
ency to  it,  lithemia,  as  well  as  neurasthenia  due  to  excessive 
mental  work  or  overstrain  of  the  nervous  system  in  any  way, 
especially  sexual  excesses  or  irregularities,  may  stand  in  a 
causal  relation  to  chronic  enteric  catarrh,  as  also  to  various 
other  derangements  and  diseases  of  the  digestive  system.  The 
most  frequent  sequence  of  events  in  these  cases  is,  according 
to  my  experience,  as  follows : 

(i)  An  inherited  neurotic  tendency;  (2)  overstrain  or 
other  injury  to  the  nervous  system  with  deficient  exercise  and 
excessive  eating,  often  provoked  by  tonics;  (3)  a  resulting  de- 
rangement of  the  digestion  either  gastric  or  intestinal,  or  both, 
and  most  commonly  some  aberration  of  the  gastric  secretion, 

715 


/l6  THE    GASTRO-INTESTINAL    CLINIC 

especially  hyperchlorhyclria ;  (4)  deranged  defecation — con- 
stipation or  diarrhea;  (5)  auto-intoxication  from  the  absorp- 
tion of  the  toxic  products  of  a  perverted  metabolism;  and  (6) 
enteritis,  which  is  often  acute  at  first,  recurring  frequently 
enough  to  set  up  finally  a  chronic  inflammatory  process,  though 
it  may  be  in  many  instances  chronic  from  the  beginning.  In 
all  the  persistent  cases,  of  course,  a  vicious  circle  becomes  es- 
tablished, and  then  the  catarrhal  process  and  auto-intoxication 
are  each  increased  by  the  other.  The  disease  may  result 
secondarily  from  morbid  growths  in  or  adjacent  to  the  in- 
testines, and  from  certain  affections  of  the  heart,  kidneys, 
stomach,  liver,  tuberculosis  of  the  lungs  or  the  bowels,  as  well 
as  from  organic  disease  in  other  parts  of  the  body,  including, 
of  course,  typhoid  fever,  and  sometimes  malaria.  Influenza  is 
perhaps  the  most  frecpent  acute  cause  of  the  disease,  and  the 
recent  large  increase  in  the  prevalence  of  appendicitis  is 
possibly  a  direct  result  of  repeated  attacks  of  grippe  involving 
the  intestines.  A  slowing  of  the  circulation,  in  consequence  of 
cardiac  or  hepatic  disease,  is  often  also  a  predisposing  cause 
of  chronic  enteritis. 

Pathology. — In  chronic  intestinal  catarrh  there  are  present 
the  usual  changes  in  the  mucous  membrane  which  character- 
ize the  same  process  elsewhere.  The  mucosa  becomes  at  first 
gradually  swollen  and  thickened.  Its  color  is  grayish  or  pale 
reddish,  with  dark  or  black  pigment  in  places.  As  in  the 
acute  form  the  blood-vessels  are  enlarged,  distended,  and  often 
tortuous;  the  secretion  is  increased,  and  the  surface  of  the 
mucosa  is  covered  with  a  layer  of  viscid  mucus. 

Chronic  enteritis  may  be  hyperplastic,  with  increase  of  the 
glandular  elements,  a  marked  infiltration  of  round  cells,  and 
often  proliferation  of  the  connective  tissue,  or  atrophic  with,  in 
the  end,  a  shrinking  of  all  the  structures.  In  the  latter  type, 
which  is  a  late  development  of  the  ordinary  catarrhal  en- 
teritis, the  glands  themselves  undergo  atrophy,  and  both  the 
mucosa  and  sul)mucosa  become  thinner.  Ulcers  and  erosions 
are  frequently  present  in  this  form  or  stage  of  the  inflamma- 


CHRONIC    CATARRH    OF    THE    INTESTINES  JlJ 

tion.  As  in  inflammation  of  the  gastric  mucosa,  there  is  also 
a  form  of  chronic  enteritis  in  which  proHferation  of  the 
connective  tissue  is  the  predominant  feature,  and  then  the 
glands  secondarily  atrophy  as  a  result  of  the  pressure  of  the 
surrounding  hyperplastic  structures. 

Symptomatology. — Though  there  may  be  no  marked 
symptoms  at  first,  yet  even  in  the  lightest  case  the  patient  com- 
monly shows  some  falling  off  in  nerve  tone,  and  in  both  mental 
and  physical  vigor,  or  is  at  least  more  easily  tired  than  usual. 
There  are  likely  to  be  felt  also,  quite  early  in  any  pronounced 
case,  uncomfortable  sensations,  referred  to  some  part  of  the 
lower  abdomen.  These  come  on  two  to  four  hours,  or  even 
longer,  after  a  meal,  and  consist  usually  of  a  feeling  of 
pressure,  fullness,  or  distention  from  gases  which  often  cause 
rumbling  and  gurgling  sounds — borborygmi.  These  flatu- 
lent symptoms  frequently  constitute  the  only  discomfort  ex- 
perienced, the  bowel  movements  continuing  for  a  time  ap- 
parently normal,  though  generally  there  is  either  constipation 
or  diarrhea,  or  first  one  and  then  the  other.  When  such  an 
alternation  exists,  the  underlying  condition  is  really  one  of  con- 
stipation, the  recurring  attacks  of  diarrhea  being  due  to  the 
irritation  provoked  by  retained  masses  of  feces.  When  the 
catarrh  involves  the  colon,  the  acme  of  symptoms  generally 
occurs  shortly  before  the  stool.  In  cases  of  chronic  colitis,  in 
which  there  are  only  one  or  two  stools  daily,  and  these  in  the 
morning,  the  patient  is  likely  to  be  awakened  early  by  the  ac- 
cumulation of  gases,  with  the  resulting  discomfort  or  pains. 

In  duodenal  catarrh  the  stomach  is  nearly  always  more  or 
less  involved.  Exceptionally  then,  and  sometimes  when  the 
catarrh  affects  only  other  parts- of  the  gut,  there  may  be  nausea, 
vomiting,  and  loss  of  appetite.  Anorexia  is  indeed  a  very 
common  symptom  in  all  the  severer  forms.  Pain  or  discom- 
fort within  an  hour  or  two  after  taking  food  is  often  ex- 
perienced in  duodenal  catarrh,  and  in  these  cases,  also,  even 
with  no  demonstrable  implication  of  the  stomach,  there  is 
likely  to  be  much  eructation  of  gas,  coming  on  soon  after  be- 


yiS  THE    GASTRO-IXTESTINAL    CLINIC 

ginning  to  eat.  The  same  phenomenon  3-011  may  observe  after 
a  thorough  lavage.  This  seemed  to  me  difficult  of  explanation 
until  I  reflected  that  the  opening  of  the  pylorus  for  the  down- 
ward passage  of  the  licjuid  in  the  stomach  would  permit  an 
upward  rush  of  the  gases  which  were  distending  the  bowel. 

Vertigo,  headache,  anorexia,  and  jaundice,  or  at  least  a 
very  muddy  color  of  the  skin,  are  much  more  frequently  en- 
countered in  catarrh  of  the  duodenum  than  when  this  most  im- 
portant part  of  the  digestive  tube  is  not  involved.  A\'hen  the 
rectum  shares  in  the  catarrhal  process,  the  patient  will  usually 
complain  much  of  tenesmus  after  the  evacuations.  There  may 
be  no  really  painful  straining,  but  instead  only  a  feeling  that 
the  stools  are  not  complete — as  though  some  feces  remain 
which  cannot  be  expelled. 

In  severe  or  advanced  cases  of  catarrh  in  any  part  of  the 
bowels,  there  is  alwa3's  much  self-poisoning  from  the  absorp- 
tion of  the  products  of  faulty  metabolism,  and  you  may  expect 
to  find  many  of  the  typical  symptoms  of  lithsemia  and  nerve 
exhaustion,  including  especially  palpitation  of  the  heart  with 
cold  extremities,  more  or  less  anaemia,  insomnia,  either  mental 
depression  or  great  irritability,  impaired  memory,  physical 
debility,  etc.  In  bad  cases  which  do  not  respond  to  treatment, 
you  will  be  likely  to  observe  also  a  more  or  less  progressive 
emaciation  and  loss  of  strength,  as  well  as  a  gradual  aggrava- 
tion of  all  the  symptoms,  including  especially  a  stubborn 
diarrhea  in  advanced  cases  which  involve  a  large  portion  of 
the  bowel. 

Boas^  calls  attention  to  the  great  variability  of  different 
cases  of  chronic  enteric  catarrh,  some  running  an  almost  latent 
course,  while  others  are  marked  by  very  troublesome  symp- 
toms. He  has  found  the  general  condition  of  the  patients  in 
cases  characterized  by  constipation  to  be  usually  little  altered, 
while  in  chronic  enteritis  accompanied  by  copious  diarrhea, 
especially  if  it  involve  predominantly  the  upper  bowel,  the  con- 
dition of  the  patient  is  much  more  serious.     This  one  would 

'  "  Diagnostik  u.  Therapie  d.  Darmkrankheiten,"  Leipzig,  1899,  p.  222. 


CHRONIC    CATARRH    OF    THE    INTESTINES  7^9 

naturally  expect,  since  chronic  enteritis  with  diarrhea,  which 
persists,  is  usually  either  complicated  by  ulceration,  or  else 
considerable  portions  of  both  the  small  and  large  intestines 
are  involved.  Moreover,  very  much  more  poison  is  absorbed 
from  liquid  feces  than  from  those  that  remain  dry  or  formed. 

The  objective  symptoms  of  intestinal  catarrh  have  to  do 
mainly  with  the  character  of  the  stools,  as  well  as  with  signs 
to  be  elicited  by  palpation  and  by  succussion  or  clapotage  (tap- 
ping the  abdomen  with  the  finger  tips  to  produce  splashing 
sounds).  Inspection  of  the  uncovered  abdomen  may  also 
afford  information,  by  showing  tympanitic  swellings  over 
either  the  whole  lower  abdomen,  or  over  the  cecum  or  other 
portions  of  the  intestines.  These  would  render  probable  the 
existence  of  a  spastic  condition  or  irregular  contractions  of 
the  circular  fibers  of  the  bowel,  though  not  diagnostic  of  such 
a  complication. 

In  any  well-marked  case  of  enteric  catarrh  palpation  will 
generally  reveal  tender  areas  corresponding  to  the  locality  of 
the  part  of  the  intestine  involved,  especially  when  this  is  the 
colon,  and  these  will  be  most  readily  demonstrated  when  hard 
feces  are  present.  Such  areas  are  most  commonly  found  over 
the  cecum,  sigmoid  flexure,  or  the  middle  portion  of  the  trans- 
verse colon.  If  the  disease  has  continued  long,  you  will  often 
be  able  to  detect  by  deep  and  careful  palpation  the  appendix, 
thickened  by  a  catarrhal  inflammation  and  more  or  less  sensi- 
tive to  pressure.  In  such  cases  considerably  more  muscular 
resistance  will  be  felt  in  palpating  over  the  right  than  over  the 
left  iliac  fossa.  In  cases  in  which  there  is  much  catarrh  of  the 
cecum,  you  will  likely  be  able  to  elicit  a  splashing  sound  over 
that  region  at  almost  any  time  when  there  is  diarrhea,  and 
often  in  the  constipated  cases  as  well,  especially  a  few  hours 
after  much  fluid  has  been  taken,  though  this  sign  may  signify 
merely  dilatation  of  the  cecum.  The  splash  may  often  be  ob- 
tained over  other  parts  of  an  atonic  colon  at  a  suitable  time 
after  taking  food  or  drink.  Palpation  may  also  reveal  masses 
of  hardened  feces  in  any  part  of  the  colon. 


720  THE    GASTRO-INTESTINAL    CLINIC 

All  kinds  of  stools  may  be  observed  in  chronic  enteritis, 
from  thin  watery  ones  passed  three  to  ten  times,  or  even  much 
oftener  in  the  twenty-four  hours,  to  those  apparently  normal 
in  all  respects.  Usually,  however,  more  or  less  mucus  will  be 
found  with  the  evacuations — intimately  mixed  through  them, 
as  a  rule,  when  the  trouble  is  mainly  in  the  upper  intestine, 
and  smeared  over  the  outside  of  formed  stools  when  the  colon 
only  or  chiefly  is  affected. 

A  close  inspection  of  the  stools,  even  macroscopically,  will 
often  enable  you  to  distinguish  particles  of  undigested  food, 
and  by  the  aid  of  the  microscope  you  can  detect,  in  most  cases 
of  catarrh,  undigested  muscle  fibers,  starch  granules,  lumps  of 
casein,  fat  globules,  etc.  Neither  blood  nor  pus  is  usually  to 
be  met  with  in  uncomplicated  enteric  catarrh  of  moderate  in- 
tensity, and  when  present  in  considerable  quantity  would  point 
to  complications.  Even  the  entire  absence  of  mucus  for  long 
periods  does  not  exclude  chronic  enteritis,  since  there  may 
be  atrophy  of  the  mucous  membrane,  or  the  mucus  may 
be  retained  in  pockets  for  considerable  periods  before  being 
passed. 

Diagnosis. — Well-marked  chronic  intestinal  catarrh  you 
will  easily  recognize  by  the  description  above  given;  but  the 
atypical  cases  may  well  bother  any  physician  until  they  have 
been  for  some  time  under  observation.  The  chief  distinguish- 
ing features  are  at  least  a  slight,  and  sometimes  very  marked, 
impairment  of  the  general  health  in  connection  with  pain  or 
discomfort  in  the  bowels,  and  tender  areas  over  them,  irregu- 
larity in  the  character  or  number  of  the  stools,  and  usually  the 
frequent  or  occasional  presence  of  mucus  in  them.  There  is 
also  nearly  always  an  excessive  formation  of  gases  in  the  in- 
testines, much  of  which,  however,  when  the  disease  is  in  the 
upper  intestine,  may  escape  upward  into  the  stomach  and  be 
eructated.  The  greatest  complaints  from  bloating  or  gaseous 
distention  will  naturally  be  made  in  those  cases  complicated 
with  constipation.  An  important  confirmatory  sign  is  the 
presence  in  the  urine  of  indican  or  aromatic  sulphates,  or  both, 


CHRONIC    CATARRH    OF    THE    INTESTINES  721 

in  excessive  quantities,  though  these  may  be  found  also  in 
cancer,  tuberculosis,  intestinal  obstruction,  intestinal  indiges- 
tion, etc.,  and  may,  exceptionally,  be  absent  in  mild  or  mod- 
erate cases  of  chronic  enteritis. 

The  greatest  difficulty  you  are  likely  to  encounter  will  be  in 
differentiating  chronic  enteric  catarrh  from  nervous  forms  of 
diarrhea,  resulting  from  vaso-motor  paresis.  Boas  holds  that 
in  some  instances  the  diagnosis  between  these  can  scarcely  be 
made.  But  in  genuine  nervous  diarrhea  there  is  no  mucus, 
and  rarely  any  pain;  the  stools  are  not  fetid,  no  indicanuria 
nor  excess  of  the  aromatic  sulphates  is  likely  to  appear  in  the 
urine,  and  the  attacks  are  usually  transient,  as  well  as  coinci- 
dent with  an  increase  in  the  other  neurasthenic  or  hysteric 
symptoms.  If  such  diarrheal  attacks  recur  often,  and  particu- 
larly if  they  incline  to  linger  for  days  at  a  time,  it  may  well  be 
suspected  that  a  catarrhal  process  has  been  set  up.  Constipa- 
tion from  stricture,  tumors,  etc.,  is  to  be  differentiated  also; 
but  when  this  persists  long,  a  catarrhal  process  nearly  always 
results. 

Above  all,  do  not  forget  that  intestinal  catarrh  is  by  no 
means  synonymous  with  diarrhea,  the  majority  of  the  cases 
being  accompanied  at  first,  at  least,  by  constipation. 

Prognosis. — This  is  one  of  the  most  difficult  of  all  non- 
malignant  diseases  to  cure.  Yet  it  is  always  curable  by  ap- 
propriate treatment  in  the  earlier  stages,  and  generally  in  the 
later  ones,  provided  the  patients  can  afford  the  necessary  out- 
lay of  time  and  money  with,  often,  prolonged  rest  from  an  in- 
jurious occupation,  and  especially  if  they  are  willing  to  change, 
radicalh^  and  permanently,  the  faulty  habits  as  to  diet  and  ex- 
ercise (often  dress  as  well)  which  you  will  usually  find  to 
have  been  prominent  in  the  causation.  Even  when  the  ap- 
pendix has  become  involved  in  the  catarrhal  process,  as  hap- 
pens ultimately  in  a  large  proportion  of  prolonged  cases,  a 
cure  without  operative  intervention  may  sometimes  reward 
your  persistent  efforts ;  but  in  the  more  stubborn  cases  re- 
moval of  the  appendix  is  usually  desirable,  and,  in  persons 


722  THE    GASTRO-INTESTINAL    CLINIC 

not  able  to  afford  a  long  course  of  treatment,  is  often  indis- 
pensable, especially  when  there  occur  occasionally  acute 
attacks. 

Treatment. — The  dietetic  is  the  most  difficult  part  of  the 
treatment,  and  the  most  important.  An  almost  exclusive  diet 
of  meat,  with  a  very  free  use  of  hot  water — the  pulp  of  lean 
beef,  or  finely  hashed  beef  or  mutton,  with  just  enough  of 
lettuce  or  celery  to  act  as  a  relish,  and  a  slice  or  two  of  stale 
bread  and  butter  daily — kept  up  for  a  few  weeks,  will  often 
accomplish  brilliant  results  in  controlling  catarrh,  either  gas- 
tric or  intestinal;  but  there  are  important  contra-indications 
to  such  a  regimen.  When  a  dilated  stomach,  or  one  with  a  very 
poor  motor  power,  coexists,  as  often  happens,  the  large 
amounts  of  water  will  disagree,  unless  given  one  glass  at  a 
time,  and  sometimes  even  then.  When  there  is  a  very  feeble 
heart,  the  superabundance  of  fluid  involves  dangers,  and  when 
the  heart  is  enfeebled  by  gouty  conditions,  that  is,  overtaxed 
by  forcing  the  blood  through  arterioles  contracted  by  the 
alloxuric  bases  or  other  poisons  produced  in  lithsemia,  there 
is  the  added  danger  that  the  overplus  of  meat  will  aggravate. 
Moreover,  in  patients  having  rheumatism  or  arteriosclerosis, 
as  in  the  case  of  so  many  elderly  ones,  the  meat  diet  often 
proves  harmful. 

But  even  in  persons  in  whom  no  such  contra-indications 
appear,  it  is  not  always  safe.  I  once  saw  a  young  lady  become 
insane,  as  a  result  apparently  of  such  a  diet  after  a  few  weeks' 
use  of  it;  and  in  any  case,  it  can  scarcely  be  continued  in  a 
strict  form  longer  than  three  or  four  weeks.  An  occasional 
fast  of  five  to  ten  days  will  sometimes  effect  a  cure  when  the 
cause  was  an  overtaxed  liver  and  digestive  glands.  Rest  is 
one  of  our  very  best  remedies  for  any  diseased  organ. 

When  the  meat  diet  does  not  suit,  or  when  the  intestinal 
catarrh  persists,  after  trying  it  for  a  sufficient  length  of  time, 
your  best  reliance  will  be  upon  good  stale  white  or  whole 
wheat  bread  (not  very  coarse  bran  or  brown  bread)  and  butter, 
together  with  some  of  the  well-baked  cereal  foods  in  a  dry 


CHRONIC    CATARRH    OF    THE    INTESTINES  723 

form,  so  as  to  require  thorough  mastication  and  insahvation. 
Thoroughly  cooked  rice  and  gluten  preparations  are  allowable. 
Eggs,  except  fried,  can  also  be  eaten  once  or  twice  daily,  and 
good  fresh  lean  fish  may  be  taken.  Fresh  milk,  preferably 
boiled  or  sterilized,  and  a  small  or  even  moderate  amount  of 
cream  are  generally  well  borne,  though  there  are  cases  in  which 
they  wholly  disagree,  and  Boas  tabooes  milk  entirely  in  this 
affection.  Scraped  or  hashed  meat  once  or  twice  a  day  is  de- 
sirable in  most  cases,  and  sometimes  steak,  chops,  or  even 
tender  broiled  ham  in  small  quantities,  well  chewed,  agree  per- 
fectly. Sugar  and  the  fruits  always  aggravate  in  the  severer 
cases,  and  when  there  is  diarrhea,  especially,  should  be  rigor- 
ously prohibited.  The  vegetables  are  nearly  as  bad,  and 
though  a  little  celery,  lettuce,  asparagus  tops,  or  even  baked 
white  potato  may  not  always  seem  at  once  to  disturb,  much  of 
them  at  one  time  usually  does,  and  the  potato  especially  is 
likely  to  increase  the  fermentation.  Summer  squash,  pumpkin, 
egg  plant,  etc.,  may  be  cautiously  tried  in  the  lighter  cases  with 
constipation.  All  vegetables  agree  best  in  purees.  Most  of 
them  are  positively  hurtful  in  well-marked  cases  of  intestinal 
catarrh.  As  to  beverages,  alcohol  should  be  generally  avoided, 
but  tea  and  coffee  may  be  allowed  in  moderation,  provided  the 
patient  be  not  lithsemic.  Chocolate  and  cocoa  generally  disa- 
gree on  account  of  their  accompanying  sugar  and  large  con- 
tent of  fat,  but  I  have  recently  been  seeing  good  results  in 
patients  who  partook  moderately  of  a  preparation  called  Plas- 
mon-Cocoa,  which  contains  no  sugar,  and  yet  is  fairly  pala- 
table and  very  nourishing.  Cereal  coffee  and  hot  water 
flavored  with  milk,  or  otherwise,  to  suit  the  taste  are  safe 
drinks,  and  in  Europe  a  little  claret  is  often  allowed  when  the 
gastric  juice  is  deficient.     Iced  drinks  are  injurious. 

As  to  the  other  parts  of  the  treatment,  it  is  impossible  to 
outline  any  definite  course  which  will  cure  all  cases.  Indeed, 
in  no  field  are  experience,  diagnostic  acumen,  an  intimate 
knowledge  of  all  the  remedial  measures,  good  judgment,  and 
especially  patience,  so  indispensable. 


724  THE    GASTRO-INTESTINAL    CLINIC 

The  fundamental  requirements  are  to  bring  up  the  nerve 
tone  and  improve  the  circulation  in  the  intestines  by  whatever 
means  will  best  succeed.  The  most  practicable  and  effective 
are,  in  general,  the  milder  forms  of  outdoor  exercise,  includ- 
ing golfing,  rowing,  and  horseback  riding,  together  with 
massage  (except  when  there  is  hyperchlorhydria,  or  a  spastic 
condition  of  the  bowels),  electricity  and  hydriatic  procedures, 
such  as  colonic  flushing  with  mild  antiseptic  or  astringent  so- 
lutions, and  wet  packs  and  jet  douches  to  the  abdomen.  An 
equally  important  thing  is  to  secure  good  drainage — perfect 
elimination  through  the  bowels,  kidneys,  and  skin.  This,  can 
often  be  accomplished  by  the  above-named  measures,  and 
drinking  freely — even  copiously  sometimes — of  pure  water, 
when  this  is  not  otherwise  contra-indicated.  In  some  cases, 
however,  a  cautious  use  of  the  gentler  and  least  irritating 
laxatives,  such  as  olive  oil,  by  mouth  or  enema,  Purpetrol,  a 
highly  purified  preparation  made  from  a  Russian  coal  oil,  cas- 
cara  sagrada,  sulphur,  or  the  salines  (especially  the  phosphate 
or  sulphate  of  sodium)  will  best  effect  this  object.  It  is  nearly 
always  indispensable  that  there  should  be  one  complete  evacua- 
tion every  day,  or  at  least  every  other  day,  but,  if  possible,  this 
should  not  be  loose — never  watery.  Even  in  the  cases  in  which 
constant  diarrhea  has  become  established,  flushing  the  colon 
with  a  normal  salt  solution,  followed  by  injections  of  antisep- 
tics, and  when  necessary  also  an  astringent,  such  as  a  teaspoon- 
ful  of  bismuth  to  the  pint  of  tepid  water,  nearly  always  gives 
better  results  than  opiates  and  astringents  by  the  mouth.  These 
last  are  rarely  necessary,  even  temporarily,  and  used  long  al- 
ways do  harm.  Dr.  Deardorff  of  San  Francisco  recommends 
in  chronic  colitis  the  injection  every  other  evening  of  several 
quarts  of  a  normal  salt  solution,  and  on  the  alternate  evenings 
the  following: 

Ac.  carbol 3  iss 

Glycerin f  1  iii 

Listerin q.  s.  ad  f  ^  vi 

M.  Sig. :  Add  two  tablespoonfuls  to  two  quarts  of  cool  or  tepid 
water  and  inject  every  other  evening. 


CHRONIC    CATARRH    OF    THE    INTESTINES  72 5 

I  have  used  this  in  numerous  cases  with  excellent  results  in 
nearly  all,  but  have  found  that  carbolic  acid,  given  by  the 
bowel,  will  aggravate  any  coexisting  hyperchlorhydria  almost 
as  quickly  as  when  taken  by  the  mouth. 

Recently  I  have  seen  a  very  stubborn  case  of  chronic  colitis 
cured  by  injections  of  bismuth  with  cotton-seed  oil.  When 
there  is  persistent  diarrhea,  the  massage  should  be  light,  or 
omitted,  and  so  also  when  there  is  constipation  of  spastic 
origin.  The  milder  astringents,  such  as  bismuth,  ichthalbin, 
tannalbin,  and  tannigen,  may  also  be  given  by  the  mouth  in 
5-  to  lo-grain  doses  after  every  stool,  when  the  bowels  are  per- 
sistently loose. 

In  all  stubborn  cases  the  stomach  should  be  tested  by 
washing  out  or  extracting  the  contents,  four  to  six  hours 
after  a  meal,  to  ascertain  the  degree  of  gastric  motor  power 
and  the  character  of  the  chyme  being  delivered  into  the  in- 
testines— whether  or  not  well  digested,  and  whether  irritat- 
ing from  an  excess  of  either  free  HCl  or  organic  acids  result- 
ing from  fermentation.  When  in  this  way  you  find  the  stom- 
ach contents  excessively  irritating  from  a  too  high  acidity,  you 
will  naturally  need  to  remove  such  a  cause  of  the  intestinal 
trouble,  before  you  can  hope  to  effect  a  cure.  The  appropriate 
treatment  of  the  gastric  disease  will  need  to  be  instituted,  and 
if  there  be  much  stagnation,  gastric  lavage,  for  a  time,  will  be 
indispensable. 

Supposing  the  cause  or  causes  to  have  been  removed,  the 
remedies  already  mentioned  will  rarely  fail  to  control  the 
symptoms,  except  in  the  severest  cases.  When  one  or  two  loose 
stools  recur  every  morning,  I  have  seen  very  small  doses  of 
podophyllin — grain  i-ioo  every  three  to  four  hours — act  most 
happily  in  restraining  it  (see  Lecture  XXXIV.).  Sometimes 
I- 10  grain  doses  of  calomel  every  two  to  four  hours  prove 
the  most  efficient  means  of  stopping  the  offensive  diarrhea 
which  results  as  a  complication  from  taking  cold,  or  more 
often  from  some  imprudence  in  diet.  The  same  small  doses  of 
calomel  given  for  one  or  two  days  in  each  week,  or  until  bile- 


T2^  THE    GASTRO-INTESTINAL    CLINIC 

tinged  stools  result,  are  frequently  a  useful  adjuvant  in  chronic 
intestinal  catarrh. 

Various  spring  waters  have  been  recommended  for  this  af- 
fection, including  especially  those  of  Carlsbad.  Plombieres, 
and  Vichy  in  Europe,  and  those  of  Saratoga  (N.  Y.)  and  Bed- 
ford (Pa.),  and  they  often  exert  a  curative  influence;  but  pa- 
tients possibly  profit  as  much  by  the  rest  from  business 
or  social  cares,  and  change  of  scene  at  such  resorts,  as  from 
the  medication.  The  sulphate  of  sodium,  dissolved  in  hot 
water,  and  sometimes  combined  with  a  little  bicarbonate  or 
chloride  of  sodium,  will  usually  prove  nearly  as  useful  as  the 
imported  spring  waters  taken  at  home. 

In  the  severe  cases  having  diarrhea,  and  those  in  which 
constipation  is  complicated  with  serious  nervous  exhaustion, 
rest  in  bed,  for  two  to  four  weeks  at  least,  should  be  insisted 
upon.  This  not  only  secures  needed  physical  and  mental  rest, 
but  insures  better  nursing  and  a  closer  study  of  the  patient's 
case  by  the  physician. 

In  all  the  cases  in  which  the  strength  is  not  seriously  re- 
duced, the  gymnastic  exercises  for  the  abdominal  muscles  de- 
scribed in  Lecture  XXIII. ,  or  other  ecjually  efficient  ones, 
should  be  practiced  daily  to  increase  the  tonicity  of  the  mus- 
culature, and  improve  the  circulation  in  the  parts.  This  should 
not  be  neglected,  even  when  massage  is  regularly  applied, 
unless  the  patient  is  unecjual  to  any  active  exercise. 

In  the  more  obstinate  forms  of  the  disease,  a  valuable 
method  of  treatment  to  supplement  the  dietetic  and  other  meas- 
ures already  described,  is  that  introduced  by  Doumer.^  It 
consists  of  the  passage,  by  means  of  large  flat  electrodes,  of 
as  full  doses  of  galvanism  as  can  be  borne  through  the  abdo- 
men from  one  iliac  fossa  to  the  other.  Very  large  doses  can 
safely  be  applied  in  this  way.  Doumer  runs  the  current  gradu- 
ally up  to  70  or  even  80  ma.  Once  a  minute  he  reduces  it  to 
40  ma.,  and  the  current  having  been  reversed  to  produce  a 
momentary  shock,  the  dose  is  again  slowly  increased  to  the 
1  Gaz.  des  Hop.,  October  27,  1900. 


CHRONIC    CATARRH    OF    THE    INTESTINES  ^2^ 

former  limit.  He  begins  with  a  ten-minute  sitting  daily,  and 
later  lessens  it  to  three  times  a  week.  This  is  kept  up  for 
from  four  to  six  weeks. 

Other  extraordinary  methods  applicable  in  stubborn  chronic 
catarrhs  of  the  colon  especially,  include  that  by  means  of  hy- 
droelectric applications,  which  you  will  find  described  in  Lec- 
ture XXVI.  and  Turck's  method  by  lavage  of  the  colon  de- 
scribed in  Lecture  XXVIL ;  also  the  injection  of  carbon 
dioxide  (COJ,  recommended  by  Dr.  A.  Rose  and  described 
in  Lecture  XXVIL  Applications  of  the  static  wave  current 
over  the  lower  abdomen  have  proved  useful  in  my  experience 
for  such  cases. 

To  sum  up :  the  most  useful  measures  in  my  hands  have 
been  ( i )  a  bland,  easily  digestible  and  at  the  same  time  very 
nourishing  diet;  (2)  keeping  the  bowels  regularly  open  by  the 
mildest  means,  avoiding  purgative  drugs  so  far  as  possible  and 
relying  largely  upon  enemas  of  olive  oil;  and  (3)  the  use  three 
times  a  week  of  electricity  in  the  form  of  the  continuous  cur- 
rent applied  according  to  the  Doumer  method  described  on  the 
preceding  page,  or  by  passing  doses  of  25  to  30  M.  A.  through 
the  body  from  the  sacrum  (positive  pole)  to  the  middle  of  the 
lower  abdomen  in  front  (negative  pole),  the  seances  to  last  ten 
to  fifteen  minutes  each.  In  the  cases  associated  with  much 
nervous  debility  the  patient  will  progress  better  if  kept  at  rest 
recumbent  and  given  passive  exercise  only  by  means  of  massage 
and  general  faradization. 

The  French  physicians  seem  to  consider  most  cases  of 
chronic  enteritis  as  mucomembranous  and  recommend  the  more 
stubborn  ones  either  to  bathe  in  the  waters  of  Plombieres  and 
take  colon  douches  of  them  at  the  same  time,  or  to  drink  the 
waters  at  Chatel-Guyon .  I  have  known  some  cases  to  be  cured 
at  Plombieres  and  one  patient  to  be  so  seriously  depressed  by 
the  treatment  there,  that  after  waiting  three  weeks  for  the 
promised  secondary  gain,  he  was  only  rescued  by  a  course  at 
Kissengen  from  what  threatened  to  become  a  disastrous  con- 
dition. 


LECTURE  LXVII 

APPENDICITIS,    ITS    SYMPTOMS,     DIAGNO- 
SIS, ETC. 

Inflammation  in  the  cecal  region  formerly  classed  as 
typhlitis,  perityphlitis,  or  paratyphlitis,  is,  in  accordance  with 
a  newer  pathology,  now  called  appendicitis.  It  is  believed 
nearly  always  to  originate  in  the  appendix  vermiformis  and  ex- 
tend later  in  a  certain  proportion  of  the  cases  to  the  surround- 
ing tissues.  There  is  doubtless  in  most  cases  a  previously 
existing  catarrhal  process  in  the  colon,  which  involves  the 
cecum  in  a  more  or  less  obscure  way,  not  often  provoking 
active  or  serious  symptoms  there.  Finally,  when  the  process 
extends  to  the  narrow  piece  of  gut  known  as  the  appendix 
vermifonnis,  and  has  produced  enough  swelling  of  the  mucous 
membrane  of  that  structure  to  interfere  with  free  drainage  of 
its  contents  into  the  large  bowel,  threatening  symptoms  begin. 
But  it  simplifies  matters  to  regard  the  place  where  the  serious 
symptoms  generally  arise  as  the  source  of  the  mischief  and 
name  the  disease  accordingly.  Very  exceptionally,  the  attack 
is  merely  a  typhlitis  or  inflammation  of  the  cecum  from  first 
to  last,  no  other  structure  being  involved;  but  such  cases  are 
admittedly  rare. 

The  Different  Forms  of  Appendicitis. — Numerous  varieties 
of  appendicitis  have  been  described,  and  the  subject  thus  quite 
unnecessarily  complicated.  For  example,  the  following  classes 
have  been  named:  (i)  appendicular  colic;  (2)  simple  acute 
catarrhal  appendicitis;  (3)  chronic  catarrhal  appendicitis,  (a) 
oblitcrative  and  (b)  persistent;  (4)  interstitial  appendicitis; 
(5)  ulcerative  appendicitis;  (6)  purulent  appendicitis  without 
perforation   or   any  periappendicitis;    (7)    purulent   appendi- 

728 


APPENDICITIS  729 

citis  with  leaking  of  pus  into  the  peritoneal  cavity  through  a 
small  perforation  or  otherwise,  producing  local  peritonitis  and 
a  limited  walled-off  abscess;  (8)  purulent  appendicitis  with 
extraperitoneal,  retrocecal  abscess  from  the  escape  of  pus 
through  a  perforation  into  the  connective  tissue  behind  the 
cecum;  (9)  purulent  appendicitis,  with  large  escape  of  pus 
through  a  perforation  into  the  peritoneal  cavity  and  the 
production  of  general  peritonitis;  (10)  gangrenous  appen- 
dicitis. 

All  the  foregoing  are  possible  forms  of  the  disease,  or  pos- 
sible developments  of  an  attack  which  began  as  a  simple  catar- 
rhal inflammation  of  the  appendix,  or  at  least  extended  to  it 
from  a  similar  process  in  the  cecum,  which  produced  no  note- 
worthy symptoms  until  it  invaded  the  narrower  tube,  the 
swelling  of  whose  mucous  membrane  caused  obstruction  of  its 
lumen.  You  should  know  that  what  is  apparently  a  simple 
catarrhal  inflammation  of  the  appendix  may  result  in  an 
abscess,  or  exceptionally  take  any  of  the  above-mentioned 
forms,  and  it  is  also  important  to  understand  clearly  that  the 
latter  are  all  merely  manifestations  of  one  disease  process.  A 
better  classification  is  based  virtually  upon  the  degree  of  vir- 
ulency  of  the  infecting  germs  and  divides  the  disease  into  two 
forms:  (i)  the  simple  catarrhal,  and  (2)  the  severe  form 
which  is  likely  to  result  in  the  rapid  formation  of  pus,  with 
perforation  and  possibly  gangrene  following  in  a  considerable 
proportion  of  the  cases.  The  so-called  appendicular  colic  prob- 
ably never  occurs  except  in  an  appendix  already  the  site  of  a 
catarrhal  process ;  and  the  ulcerative  form  may  develop  from 
any  severe  or  prolonged  case  of  catarrhal  appendicitis.  In  all 
the  forms  there  is  more  or  less  involvement  of  the  interstitial 
connective  tissue,  but  in  some  cases  this  tissue  is  predominantly 
affected. 

.ffitiology. — The  aetiology  of  appendicitis  has  been  much 
disputed.  The  former  view  was  that  the  disease  is  always 
due  to  the  lodging  of  fruit  seeds,  other  foreign  bodies,  or 
fecal  concretions  in  the  appendix.     A  large  number  of  autop- 


730  THE    GASTRO-INTESTINAL    CLINIC 

sies  have  proved  that  this,  though  one  of  the  possible  causes, 
is  by  no  means  the  most  frequent  one.  Different  series  of  au- 
topsies have  revealed  foreign  bodies  or  concretions  of  some  kind 
(mostly  fecal)  in  from  one-twentieth  to  somewhat  more  than 
one-third  the  total  number  of  cases  studied.  The  cause  in 
other  cases  is  traumatism,  twisting  of  the  appendix  from  over- 
distention  of  the  cecum  or  ileum,  but  is  most  generally  in  all 
probability  an  extension  of  an  inflammatory  catarrhal  process 
from  the  cecum  to  the  mucous  membrane  of  the  appendix 
itself.  Both  pus  cocci  and  the  bacillus  coli  communis  are  be- 
lieved to  be  able  to  set  up  the  process,  but  the  latter  is  by  far 
the  most  frequent  infecting  agent. 

A.  O.  J.  Kelly  of  Philadelphia  has  written  the  most  rational 
and  lucid  explanation  of  the  origin  and  development  of  ap- 
pendicitis which  has  yet  appeared  anywhere.  It  forms  a  part 
of  Deaver's  "  Treatise  on  Appendicitis,"  third  edition.  Kelly 
has  made  a  thorough  investigation  of  the  subject  based  upon  a 
careful  study  of  577  appendices,  all  but  21  of  which  were  ex- 
amined microscopically.  Calculi,  even  when  found  in  the 
appendix,  are  considered  by  him  to  have  been  the  consequence, 
not  the  cause,  of  the  inflammation  of  the  mucosa.  The  swelling 
of  the  latter  produces  frequent  occlusion  of  the  tube,  as  happens 
in  the  case  of  all  similar  narrow  structures  lined  by  a  mucous 
membrane.  The  occlusion  leads  to  stagnation  of  the  contents, 
with,  as  a  consequence,  increased  virulency  of  the  colon  bacilli 
or  other  germs  thus  imprisoned. 

The  pathology  is  now  sufficiently  well  understood.  The  in- 
flammation attacks  first  the  mucous  membrane  of  the  appendix 
(swelling  and  erosion)  and  then  involves  in  succession  the 
submucous  and  muscular  layers,  and,  in  cases  not  previously 
arrested,  finally  extends  to  the  serous  coat,  producing  a  local 
peritonitis.  At  a  comparatively  early  stage  of  the  process  the 
swollen  membrane  may  close  completely  the  opening  into  the 
cecum,  and  portions  of  feces  with  the  secretions  of  the  part 
may  thus  be  retained  and  undergo  decomposition  within  the 
appendix.     In   favorable  cases,  especially  when  the  colon  is 


APPENDICITIS  731 

regularly  emptied  every  day  by  a  sufficient  bowel  movement, 
this  swelling  subsides  enough  to  allow  the  contents  to  be  ex- 
pelled, this  occurring  often  after  an  attack  of  severe  colic 
(appendicular  colic).  In  less  fortunate  cases  in  which  the 
infection  is  greater,  or  the  recuperative  powers  of  the  patient 
less,  and  feeding  by  the  mouth  not  prevented,  the  occlusion 
persists,  the  contents  of  the  appendix  become  purulent,  and  we 
have  then  established  a  collection  of  pus  in  the  appendix  which, 
however,  may  still  possibly  find  a  safe  vent  spontaneously. 
Under  favorable  conditions,  even  after  this  stage  has  been 
reached,  the  opening  into  the  bowel  is  sometimes  re-established, 
and  the  pus  drains  harmlessly  away.  Under  less  fortunate 
conditions  the  walls  of  the  appendix  are  infiltrated  with  in- 
flammatory exudate,  the  adjacent  coils  of  the  intestines  become 
agglutinated  to  the  diseased  structures,  and  with  or  without 
the  escape  of  a  small  amount  of  pus  from  within  the  appendix, 
a  true  abscess  cavity  is  established  which,  as  a  rule,  when 
absolute  rest  of  the  parts  has  been  maintained,  is  completely 
walled  off  from  the  rest  of  the  peritoneal  cavity.  Such  an 
abscess  may  rupture  into  the  peritoneum  with  rapidly  fatal 
results,  or  into  some  part  of  the  intestine,  into  the  rectum, 
vagina,  .bladder,  or  any  other  neighboring  viscus  which  may 
happen  to  become  attached  to  the  wall  of  the  abscess  by  ad- 
hesive inflammation.  Some  such  opening  is  the  most  frequent 
result  in  these  localized  forms  of  acute  appendicitis  going  on 
to  suppuration,  unless  complete  rest  of  the  body  as  well  as  of 
the  gastro-intestinal  functions  has  been  maintained  by  strict 
confinement  to  bed  and  no  food  allowed  except  by  enemas. 
\\'ith  such  an  opening,  except  it  be  into  the  bladder,  peritoneal 
cavity,  or  pleural  cavity,  the  result  may  be  favorable  and  con- 
valescence ensue.  When,  however,  the  abscess  opens  by  a  large 
opening  into  the  peritoneal  cavity,  general  peritonitis  results, 
and  very  often  (in  one-third  to  one-half  the  cases),  even  in 
spite  of  immediate  operation,  the  patient  dies.  If  it  should 
open  into  the  bladder  or  pleural  cavity,  the  danger  of  fatal  in- 
fection is  also  great.    In  a  large  proportion  of  cases  no  abscess 


732  THE    GASTRO-INTESTINAL    CLINIC 

forms,  the  inflammatory  process  resulting  from  a  true  infec- 
tipn  involves  the  various  layers  of  the  appendix,  including 
often  the  peritoneum,  and  we  have  developed  a  mild  local  peri- 
tonitis, which,  under  appropriate  treatment  with  absolute  rest, 
may  terminate  favorably  in  a  resolution  of  the  process.  In  the 
severer  cases  the  cure  is  rarely  complete,  but  there  is  usually 
left  behind  a  focus  of  disease  in  the  appendix  which,  in  a  ma- 
jority of  instances,  is  likely  to  be  lighted  up  again  into  an  acute 
inflammation  at  any  time  later  upon  a  sufficient  provocation, 
such  as  persistent  constipation,  prolonged  exposure  to  cold 
and  dampness,  etc. 

When  the  infection  is  particularly  virulent,  or  from  any 
cause  there  is  obstruction  of  the  circulation  in  the  part,  the  in- 
flammation may  take  on  a  gangrenous  form  and  prove  rapidly 
fatal.  But  in  a  certain,  though  probably  very  small  propor- 
tion of  even  the  suppurative  cases,  the  cure  may  be  complete. 
In  some  of  these  which  go  on  to  abscess  formation,  the  ap- 
pendix sloughs  away  and  is  thus  totally  destroyed,  or  an  ob- 
literative  inflammation  may  destroy  the  lumen  of  the  little 
piece  of  gut,  the  sides  being  agglutinated  and  a  solid  struc- 
ture formed.  In  still  other  cases,  especially  those  in  which  the 
inflammation  does  not  progress  beyond  the  catarrhal  stage,  the 
recovery  proves  permanent,  the  infiltrated  tissues  having  un- 
dergone resolution,  and  there  is  never  any  recurrence  of  the 
attack.  This  may  result  from  a  persistence  with  appropriate 
treatment  of  the  constipation  and  catarrh  of  the  cecum  which 
have  been  the  causes  of  the  disease,  and  from  following  thence- 
forth a  more  hygienic  mode  of  living  as  to  diet,  physical  ex- 
ercise, etc. 

Symptoms. — The  mildest  cases  of  appendicitis  give  no 
symptoms  ordinarily  beyond  a  brief  spell  of  colic,  or  even  of 
a  slight  dull  pain  with  constipation,  or  sometimes  diarrhea, 
preceding  it.  These  are  now  often  called  appendicular  colic. 
There  is  little  doubt  that  many  of  the  cases  of  so-called  bilious 
colic  which  all  of  you  have  seen  in  practice,  and  cured  rapidly 
with  the  help  of  hot  mush  poultices  and  other  simple  meas- 


APPENDICITIS  733 

ures,  were  mild  cases  of  subacute  catarrhal  inflammation  of 
the  appendix,  with  temporary  obstruction  of  the  opening. 

In  somewhat  more  marked  cases  of  acute  appendicitis  there 
will  generally  be  present  obvious  fever,  or  at  least  an  increased 
rectal  temperature,  and  also  both  severe  pain  and  localized 
tenderness  in  the  right  iliac  fossa,  with  constipation  or  some- 
times diarrhea,  and  usually  at  the  outset  one  or  more  attacks 
of  vomiting.  You  should  bear  in  mind,  however,  that  the  pain 
and  tenderness  are  not  always  in  the  right  iliac  fossa,  since 
the  appendix  may  occupy  an  abnormal  position  to  the  left  of 
the  median  line,  or  far  below  or  above  its  usual  site ;  and  even 
with  the  appendix  in  its  normal  position,  the  pain  at  first  is 
often  diffused  and  referred  to  different  parts  of  the  abdomen. 
In  all  cases,  therefore,  of  pain  and  tenderness,  in  any  part  of 
the  abdomen,  you  should  think  of  appendicitis  as  a  possibility. 

The  pain  and  tenderness  are  likely  to  be  greatest  at  what 
is  known  as  McBurney's  point,  which  is  usually  midway  of  a 
line  drawn  from  the  umbilicus  to  the  anterior  superior  spine 
of  the  ileum.  To  be  more  exact,  this  point  of  greatest  tender- 
ness should  be  about  two  inches  (5.08  cm.)  from  the  iliac  spine, 
toward  the  umbilicus  in  the  line  just  described.  In  addition  to 
pain  and  tenderness  in  this  region  you  will  find  muscular 
rigidity,  so  that  palpation  of  the  parts  beneath  the  surface  will 
be  very  difficult.  The  right  rectus  muscle  will  at  least  be  more 
rigid  than  the  left.  One  well  skilled  in  the  art  of  palpation, 
and  especially  one  accustomed  to  examine  many  appendices, 
can  generally  make  out,  in  the  early  stages  of  acute  appendi- 
citis as  well  as  in  the  chronic  forms,  an  indistinct  and  often 
somewhat  ill-defined  swelling  or  tumor  corresponding  to  the 
enlarged  appendix  with,  in  severe  cases,  the  infiltrated  tissues 
surrounding  it. 

The  symptom  fever  may  or  may  not  be  ushered  in  by  chills, 
and  is  by  no  means  always  present.  In  the  very  mildest,  as 
well  as  in  some  of  the  gravest,  forms  of  the  disease,  there  may 
be  no  fever, — at  least  no  rise  of  the  surface  temperature  or  of 
that  in  the  mouth.     Generally,  however,  there  will  be  an  in- 


734  THE    GASTRO-INTESTINAL    CLINIC 

crease  of  temperature,  which  in  the  milder  cases  is  not  likely 
toigo  above  ioo°  or  lOO  1-2°,  but  may  rise  as  high  as  103  1-2° 
or  104° — or  even,  in  very  severe  cases  with  general  peritonitis, 
105°  or  106° — in  the  rectum. 

According  to  Tiffany, nhe  temperature  in  appendicitis  should 
always  be  taken  in  the  rectum,  with  the  thermometer  placed 
as  high  up  as  possible.  Considerable  fever  will  often  be  shown 
in.  this  way  when  the  temperature  taken  in  axilla,  or  even  in 
the  mouth,  may  be  normal.  Tiffany  insists  further  that  a 
difference  of  several  degrees  between  the  temperature  in  the 
mouth  and  that  obtained  high  up  in  the  rectum  is  indicative 
always  of  peritonitis. 

In  the  mildest  cases  of  catarrhal  appendicitis  the  pulse  may 
vary  little  from  the  normal,  but  even  in  these  is  likely  to  be 
somewhat  accelerated.  In  other  cases  it  is  generally  more 
rapid  than  the  increase  in  temperature  would  lead  one  to  ex- 
pect. In  the  severer  cases  it  is  nearly  always  above  100,  and 
may  reach  130,  140,  or  even  higher  wdien  general  peritonitis 
exists.  In  all  advanced  cases  there  is  dorsal  decubitus,  with  the 
right  knee,  or  sometimes  both  knees,  flexed. 

Perforation  occurring  in  an  attack  of  acute  appendicitis 
may  lead  to  merely  a  slight  limited  extravasation,  with  the 
formation  of  a  local  abscess  and  only  a  gradual  intensifying  of 
the  symptoms,  or  may  produce  at  once  grave  and  threatening 
symptoms.  In  many  cases  there  develop  suddenly  a  high 
rectal  temperature,  and  very  acute,  often  violent  pain  which 
may  go  on  to  profound  collapse  when  the  extravasation  is 
general.  The  skin  then  is  cold  and  clammy,  and  the  pulse 
small  and  thready,  becoming  frequently  so  rapid  that  it  cannot 
be  counted.  When  general  peritonitis  has  resulted,  the  ab- 
domen may  be  either  very  tympanitic  or  extremely  rigid. 
Constipation  is  complete  and  urination  scanty  with  the  onset 
of  general  peritonitis,  and  there  develop  only  too  often  all  the 
signs  of  impending  dissolution,  including  cold  hands  and  feet, 
feeble  respiration,  and  gradually  failing  circulation.  Intellec- 
1  Wood's  "  Reference  Hand-book,"  last  edition;  article  on  Appendicitis, 


APPENDICITIS  7^35 

tion  is  generally  clear,  and  consciousness  in  fatal  cases  per- 
sists even  to  the  last. 

Diagnosis. — A  pronounced  case  of  acute  suppurative  ap- 
pendicitis may  easily  be  recognized  by  even  a  tyro  in  medicine, 
but  there  are  mild  and  irregular  forms  of  the  disease  which 
present  many  difficulties.  It  may  resemble  somewhat  a  mod- 
erate attack  of  typhoid  fever,  but  the  mode  of  onset  and 
different  course  of  the  fever  should  render  the  differentiation 
easy.  In  the  purulent  and  peritoneal  forms  there  is  leuco- 
cytosis  in  appendicitis,  but  never  in  typhoid  fever.  Obstruc- 
tion of  the  bowel,  strangulated  inguinal  hernia,  movable  right 
kidney,  stone  in  the  right  ureter  or  kidney,  extra-uterine 
pregnancy  on  the  right  side,  the  twisted  pedicle  of  an  ovarian 
cyst,  or  hepatic  colic  may  any  of  them  produce  symptoms 
similar  in  some  respects  to  those  of  appendicitis.  These,  ex- 
cept the  last,  are  devoid  of  fever  ordinarily,  and  though  appendi- 
citis may  exceptionally  pursue  an  afebrile  course,  careful 
observation  should,  within  a  short  time  enable  the  experienced 
diagnostician  to  differentiate  them. 

Subacute  perforation  of  a  duodenal  ulcer  is  often  mistaken 
for  acute  appendicitis,  and  occasionally  the  same  has  hap- 
pened in  the  case  of  a  gastric  ulcer,  situated  at  or  near  the  py- 
lorus. Moynihan,  quoted  by  Gibbon,^  is  authority  for  the  state- 
ment that  of  forty-nine  cases  of  perforated  duodenal  ulcer,  a 
diagnosis  of  appendicitis  was  made  in  eighteen.  This  could 
not  easily  occur  in  a  case  previously  under  the  care  of  an 
expert  diagnostician  unless  the  ulcer  had  been  a  latent  one. 
If  the  ulcer  had  ilni  its  course  without  the  usual  symptoms, 
and  the  perforation  had  led  to  an  accumulation  of  fluid  and 
local  peritonitis  in  the  right  lower  abdomen,  it  would  be  im- 
possible, without  an  exploratory  incision,  to  make  the  diagnosis 
from  appendicitis. 

Pus  in  the  gall  bladder,  perinephritic  abscess,  acute  tuber- 
cular peritonitis,  acute  hemorrhagic  pancreatitis,  local  peritoni- 
tis in  women  in  the  region  of  the  right  ovary  or  tube,  and  right 
1  A7ft.  Med.,  December  19,  1903. 


71^  THE    GASTRO-INTESTINAL    CLINIC 

hip-joint  disease  at  an  early  stage,  are  usually  characterized  by 
f^ver  as  well  as  pain  referred  vaguely  to  the  right  side  of  the 
abdomen,  and  might  possibly  in  some  cases  mislead  you;  but 
in  these  the  pain  would  rarely,  and  the  seat  of  tenderness 
never,  be  found  at  McBurney's  point,  except  possibly  in  tuber- 
culosis of  the  cecum,  while  the  mode  of  onset  and  other  fea- 
tures would  generally  be  very  different. 

However,  you  should  always  think  of  these  different  causes 
when  there  is  pain  in  the  right  hypochondriac  region,  and  be 
able  to  exclude  them  before  making  a  positive  diagnosis  of  ap- 
pendicitis. In  case  of  doubt  you  should  call  in  consultation  a 
medical  expert  trained  in  the  diagnosis  of  abdominal  diseases, 
one  capable  of  giving  an  authoritative  and  unbiased  opinion  as 
to  the  need  of  operative  intervention,  and  it  is  a  wise  precau- 
tion to  have  an  abdominal  surgeon  in  readiness  at  least,  and, 
preferably,  actually  associated  in  the  case  from  the  beginning 
of  the  disease. 

Physical  Signs. — A  small  tender  swelling  can  generally  be 
made  out  in  the  region  of  McBurney's  point  at  an  early  stage 
by  gentle  but  deep  and  firm  pressure,  though  the  extreme  ten- 
sion of  the  right  rectus  muscle  may  prevent,  and  this  marked 
tension  is  itself  a  valuable  diagnostic  sign.  Later,  in  severe 
cases  with  much  infiltration  or  oedema  of  the  surrounding  parts, 
a  large  doughy  mass  can  nearly  always  be  felt.  Examination 
with  the  finger  per  rectum,  or  in  women  per  vaginam,  with 
bimanual  palpation  will  help  to  make  the  diagnosis,  especially 
when  the  pain  is  referred  to  the  pelvis  and  external  palpation 
does  not  afford  conclusive  information.  Percussion  may  give 
a  dull  note  over  the  tumor  when  this  is  very  superficial,  though 
more  frequently  there  is  tympany  from  portions  of  the  in- 
testines lying  above  it. 

The  pulse  is  usually  from  90  to  100  in  the  catarrhal  cases, 
but  much  higher  in  the  purulent  and  peritoneal  ones,  frequently 
running  up  to  120  or  130,  even  in  the  absence  of  perforation. 

Clinical  Course. — Appendicitis  may  exceptionally  be  slow 
and  gradual  in  onset,  but  generally  b€gins  abruptly  and,  in  the 


APPENDICITIS  737 

severe  cases,  often  with  a  chill  followed  by  fever.  In  the 
milder  catarrhal  cases  the  pain  is  only  moderate  and  is  re- 
lieved by  appropriate  treatment.  Improvement  under  favor- 
able conditions  sets  in  soon  and  goes  on  to  recovery. 

In  the  fulminating  cases  all  the  symptoms — pain,  tender- 
ness, fever,  and  vomiting — are  likely  to  be  severe  from  the 
start,  and,  except  the  last,  which  may  be  wanting  altogether, 
increase  in  intensity  as  the  disease  progresses.  Sudden  cessa- 
tion of  pain  and  of  surface  fever  is  a  bad  sign,  pointing  to 
gangrene  or  perforation  and  general  infection  of  the  perito- 
neal cavity. 

In  other  cases  general  peritonitis  may  develop  insidiously, 
with  no  such  marked  change  in  the  symptoms.  There  may  be 
a  rise  or  little  change  in  the  temperature,  and  almost  the  only 
sign  of  the  serious  turn  in  the  case  may  be  a  gradually  ex- 
tending area  of  acute  tenderness  on  palpation,  with  increased 
tympany,  and  a  more  anxious  expression  of  the  face.  With 
such  a  development,  whether  it  be  sudden  or  gradual  in  its 
manifestations,  the  patients  in  a  large  proportion  of  cases, 
under  the  usual  methods  of  treatment,  grow  steadily  worse 
until  death  closes  the  scene. 

When  a  gangrenous  condition  of  the  appendix  superv^enes 
the  more  alarming  symptoms,  including  especially  fever  and 
pain,  often  abate,  and  unless  you  are  on  your  guard  the  ap- 
parently favorable  change  may  mislead  you  and  cause  you  to 
relax  your  vigilance.  Then  a  sudden  rupture  of  the  abscess, 
collapse,  and  speedy  death  threaten  the  patient  unless  operative 
intervention,  or  a  strict  persistence  with  rest  in  bed  and  the 
absolute  withholding  of  food,  drink,  and  disturbing  medicines 
])y  the  mouth,  according  to  the  method  of  Ochsner,^  succeeds 
in  averting  the  danger. 

Chronic  Catarrhal  Appendicitis. — In  a  considerable  pro- 
portion of  the  cases  of  apparent  recovery  from  acute  catarrhal 
appendicitis,  and  usually  when  the  suppurative  cases  pursue  a 
favorable  course  without  operation,  there  is  left  behind  a  dis- 
1  In/.  Med.  Mag.,  November,  igor. 


738  THE    GASTRO-INTESTINAL    CLINIC 

eased  mucosa  in  the  appendix,  Avhich  is  prone  to  exacerbations 
and  recurrent  acute  attacks  depending  upon  the  occlusion  of 
the  opening  by  infiltration  and  inflammatory  swelling.  Such 
a  condition  is  called  chronic  catarrhal  appendicitis.  The  same 
condition  in  mild  form  probably  nearly  always  precedes  the 
first  acute  attack  (except  when  the  latter  results  from  trau- 
matism or  the  lodging  of  a  foreign  body),  and  there  are  good 
reasons  for  believing  that  it  exists  unrecognized  for  months, 
and  sometimes  years,  in  large  numbers  of  persons.  Many  of 
these  latent  cases  under  favorable  conditions  recover  sponta- 
neously. The  disease  can  very  generally  be  held  in  abeyance, 
■and  in  the  majority  of  cases  be  gradually  improved,  a  cure 
finally  resulting  in  the  more  fortunate  ones ;  but  taking  men 
ai.d  women  as  they  are,  prone  to  be  careless  in  diet,  the  disease 
is  very  likely  to  return. 

Some  writers  insist  that  there  is  a  natural  tendency  with 
advancing  years  for  the  lumen  of  the  appendix  to  be  obliter- 
ated by  atrophy  and  that,  therefore,  after  thirty  years  of  age 
the  danger  of  developing  acute  appendicitis  steadily  lessens. 
According  to  these,  nearly  70  per  cent,  of  all  persons  over 
sixty-five  have  the  lumen  of  their  appendices  permanently 
closed,  so  that  they  could  not  have  an  attack  of  appendicitis  un- 
der any  circumstances.  It  is  well  known^  at  all  events,  that 
the  disease  is  much  more  frequent  in  children  and  young  per- 
sons, than  in  older  persons,  though  no  age  can  be  said  to  be 
immune.  The  gourmands  should  not  consider  themselves  safe 
in  being  too  reckless  in  their  diet  even  after  sixty-five. 

In  this  form  of  appendicitis  there  may  be  no  symptoms  at 
all  for  a  long  time,  the  disease  running  an  entirely  latent 
course,  except  that  often  it  may  be  noticed  by  the  patient  or 
his  friends  that  he  is  less  vigorous  or  enduring  than  pre- 
viously, or  has  a  less  ruddy  color.  Usually,  however,  there 
are  manifold  disturbances  of  the  digestive  and  nervous  sys- 
tems, including  constipation,  which  sometimes  alternates  with 
diarrhea,  intestinal  flatulence,  which  is  often  very  trouble- 
some indeed,  dull  headaches,  impaired  sleep,  and  in  short  all 


APPENDICITIS  739 

the  symptoms  generally  described  as  characteristic  of  neuras- 
thenia. It  is  often  associated  as  a  consequence,  according  to 
Edebohls,  with  a  movable  right  kidney,  and  in  the  earlier 
stages  of  such  cases  there  is  generally  hyperchlorhydria. 

The  diagnosis  of  chronic  catarrhal  appendicitis  requires  an 
unusual  degree  of  skill  in  palpation.  It  is  difficult,  except  in 
very  thin  persons,  to  make  out  the  normal  appendix,  but  one 
which  is  swollen  by  catarrhal  inflammation  should  generally 
be  felt  by  an  adept  in  palpation,  except  when  the  abdominal 
wall  is  very  thick  or  the  cecum  is  loaded  with  feces,  or  the 
surrounding  tissues  much  infiltrated,  as  occurs  after  a  recent 
acute  attack.  Edebohls  and  others  have  laid  down  elaborate 
directions  for  palpating  the  appendix,  but  the  matter  may  be 
summed  up  in  a  few  words  and  arranged  under  these  three 
heads  :  ( i )  Have  the  sense  of  touch  in  your  finger  ends  highly 
educated;  (2)  get  the  patient  to  relax  the  abdominal  muscles 
completely,  which  is  usually  best  accomplished  by  having  him 
lie  on  the  back  with  the  knees  flexed  over  a  pillow,  and  making 
a  few  gentle  stroking  motions  upon  the  abdomen,  but  some- 
times relaxation  can  only  be  caused  by  putting  the  patient  in 
a  warm  bath;  (3)  stand  on  the  patient's  right  side,  and  with 
one  hand  applied  flatly  against  the  abdomen,  press  the  finger 
tips  downward  steadily,  but  gently  at  first  so  as  not  to  excite 
contractions,  and  while  you  engage  the  patient  in  conversation 
so  as  to  divert  his  attention  as  much  as  possible  from  what 
you  are  doing,  press  them  firmly  on  down  until  finally  you  can 
feel  the  structures  on  the  back  wall  of  the  abdomen.  Then,  if 
you  will  draw  the  fingers  slowly  from  the  umbilicus  toward 
the  anterior  superior  spine  of  the  ileum  on  the  right  side,  you 
should  be  able  to  distinguish  an  enlarged  appendix  as  a  little- 
finger-shaped  resisting  body  which,  whenever  pressed  upon,  is 
likely  to  be  extremely  sensitive,  whereas  the  normal  appendix 
is  not  at  all  sensitive.  There  is  sometimes  an  advantage  in 
pressing  with  tlie  left  hand  over  the  right  or  palpating  hand. 
When  the  appendix  is  even  slightly  affected,  the  right  rectus 
muscle  is  always  very  tense.     Finding  a  very  sensitive  spot  at 


740  THE    GASTRO-IXTESTIXAL    CLINIC 

or  near  McBiirney's  point  is  not  diagnostic  of  appendicitis, 
because  this  may  be  found  in  catarrh  of  the  cecum  merely,  and 
especially  in  such  a  condition  complicated  by  ulceration. 
Neither  will  the  failure  either  to  feel  the  appendix  thickened, 
or  to  find  a  sensitive  spot  in  its  normal  site  enable  you  to  ex- 
clude the  possibility  of  chronic  appendicitis,  since  it  may  be 
displaced  to  some  other  part  of  the  abdomen,  or  be  behind  a 
cecum  which  is  full  of  soft  feces. 

Prognosis. — The  question  as  to  the  prognosis  of  appendi- 
citis has  been  greatly  complicated  by  the  controversy  long 
waged  as  to  when  surgery  should  be  invoked.  Keen  and  White 
give  the  mortality  of  "  appendicitis  and  the  attending  peri- 
typhlitis and  paratyphlitis  "  as  12.5  to  14  per  cent,  (one  out  of 
seven  to  eight  cases) ^  and  various  other  estimates  have  been 
given,  all  of  those  covering  large  series  of  cases  referring  to 
patients  treated  in  hospitals. 

In  private  practice  the  mortality  including  all  the  forms  of 
the  disease,  the  lighter  catarrhal  cases  as  well  as  the  severer 
ones,  is  very  much  less.  Ewald  has  put  himself  on  record 
("  Twentieth  Century  Practice  ")  as  believing  that  at  least  90 
per  cent,  of  all  cases  recover  under  medical  treatment  alone. 
Hemmeter-  cites  Hertzog  as  reporting  285  cases  treated  by 
medical  means  onl}-  with  an  average  mortality  of  14  per  cent. ; 
240  of  these  were  circumscribed  perityphlitis  with  a  mortality 
of  only  1.6  per  cent,  and  36  cases  of  diffuse  perityphlitis  with 
a  death  rate  of  100  per  cent.,  there  having  been  no  recoveries. 
Hemmeter  has  collected  32  cases  of  appendicitis  occurring  in 
private  practice  between  1899  ^^"^1  1901,  without  any  deaths, 
27,  of  these  ha\'ing  received  medical  treatment  only.  Two  of 
the  latter  relapsed  within  five  years,  but  the  relapses  were  re- 
covered from  without  operation. 

Richardson,  cited  by  Da  Costa,^  made  an  elaborate  study  of 
750  cases  from  which  there  was  shown  in  operated  cases  a 

'  "Am.  Text-book  of  Surgen',"  4th  ed.,  Philadelphia,  1903,  p.  839. 
'  "  Disease  of  the  Intestines,"  Philadelphia,  1902,  p.  389. 
^  "  Modern  Surgery,"  Philadelphia,  1900,  p.  793. 


m 


APPENDICITIS  741 

mortality  of  18  per  cent.;  while  the  same  surgeon,  in  a  later 
paper/  reports  520  acute  cases  observed  by  him  with  a  mortality 
of  16.4  per  cent,  under  medical  treatment,  and  21.75  P^^  cent. 
among  those  operated  on.  Richardson,  in*  a  recent  lecture,-  re- 
ports that  at  the  Massachusetts  General  Hospital  during  1901 
there  were  185  operations  for  acute  appendicitis,  with  30 
deaths,  or  16.18  per  cent. ;  41  of  these  operations  were  in  cases 
complicated  with  general  peritonitis,  with  25  deaths — 60  per 
cent.  But  in  the  operations  for  chronic  appendicitis,  interval 
operations,  etc.,  52  in  all,  there  were  no  deaths. 

The  foregoing  figures,  however,  are  altogether  too  high  for 
present  conditions.  Deaver,  who  operates  in  nearly  all  cases, 
and  with  a  skill  unsurpassed,  has  recently  reported^'  377  acute 
cases  exclusive  of  those  having  general  peritonitis,  with  a 
mortality  of  less  than  7  per  cent.,  and  both  his  and  Richard- 
son's last  large  series  of  operations  in  chronic  cases  (interval 
operations)   were  wholly  without  deaths. 

Ochsner  of  Chicago,  who  practically  never  operates  after 
the  disease  has  extended  beyond  the  appendix  itself  until  the 
attack  is  over  (except  to  open  a  circumscribed  abscess),  but 
relies  upon  non-operative  methods  of  treatment  during  the 
acute  stage  after  the  first  day  or  two,  treated  in  the  Augustana 
Hospital  during  the  calendar  year  1902,  192  acute  cases  with 
6  deaths,  about  3  per  cent.*  Fuller  statistics  of  the  mortality 
in  this  disease  under  operative  and  non-operative  measures  are 
given  in  the. succeeding  lecture  on  Treatment. 

\\"hen  an  appendiceal  abscess  opens  into  the  peritoneal  cavity, 
the  pleural  cavity,  or  the  bladder,  the  peril  to  life  is  great,  and 
a  very  large  proportion  of  such  cases  under  the  methods 
hitherto  in  vogue,  whether  with  or  w^ithout  operative  inter- 
vention, have  proved  fatal,  though  Ochsner  has  reported  one 
large  series  of  perforative  and  gangrenous  cases  treated  by 

'  Am.  Jour.  Med.  Set'.,  December,  1899. 

'^  Old  Doininion  Jour7ial,  January,  1903. 

^  Am.  Afed.,  October  17,  1903. 

•*  Med.  News,  Philadelphia  and  New  York,  May,  1903. 


742  THE    GASTRO-INTESTINAL    CLINIC 

his  new  method  with  only  5  per  cent,  mortahty.^  Every  re- 
currence of  appendicitis  increases  the  danger  of  a  fatal  ter- 
mination. Removal  of  the  appendix  during  the  first  thirty- 
six  hours,  or  before  the  disease  has  extended  beyond  that 
structure  itself,  involves  a  very  small  risk,  the  mortality  in 
good  hands  now  not  exceeding  2  or  3  per  cent.,  and  in  the  best 
hands  in  well-equipped  hospitals  is  generally  much  less — 
scarcely  i  per  cent. 

Under  appropriate  medical  treatment  alone,  catarrhal  ap- 
pendicitis nearly  always  gets  well — or,  at  least,  the  attacks  are 
recovered  from.  A  considerable  proportion  of  the  patients  do 
not  have  any  further  trouble,  and  it  is  probable  that  few  of 
them  would  relapse  if  the  best  possible  treatment  were  strictly 
followed  afterward,  including  proper  diet;  but  unfortunately 
this  can  seldom  be  insured.  AA'oods  Hutchinson  quotes  the 
late  Fenger,  one  of  the  most  brilliant  surgeons  this  countr}^ 
has  produced,  as  stating  that  "  alx)Ut  one-third  of  the  severer 
type  of  cases  recovering  from  one  attack  would  probably  never 
have  another." 

"^  hit.  Med.  Mag.,  November,  1901. 


LECTURE  LXVIII 
THE  TREATMENT  OF  APPENDICITIS 

The  treatment  of  appendicitis  is  one  of  the  earnestly  dis- 
cussed questions  of  the  day  in  the  medical  circles  both  of  Eu- 
rope and  the  United  States.  In  this  country,  where  its  true 
nature  was  first  clearly  pointed  out,  by  Fitz  of  Boston  in  1886, 
the  disease  is  treated  with  a  greater  degree  of  success  than  any- 
where else  in  the  world,  because  in  part,  no  doubt,  of  its  un- 
usual prevalence  here. 

Three  different  views  as  to  the  treatment' are  now  advocated, 
and  there  is  no  reason  to  doubt  that  the  champions  of  each  ar-; 
equally  honest  and  conscientious.     These  are  as  follows : 

1.  The  Radical  Surgical  Method. — This  is  ably  championed 
and  very  successfully  carried  out  in  practice  by  Deaver,  Price, 
and  others  of  Philadelphia,  as  well  as  by  Morris  of  New  York, 
and  Murphy  of  Chicago,  among  others.  They  hold  that  ap- 
pendicitis is  exclusively  a  surgical  disease,  and  that  to  delay 
operation  and  depend  upon  any  kind  of  non-operative  meas- 
ures at  any  stage  is  nearly  always  only  a  waste  of  time  which 
endangers  the  patient.  They  would,  as  a  rule,  operate  in  any 
stage  of  any  form  or  grade  of  the  disease  in  the  majority  of 
instances,  except  when  the  patient  is  moribund  or  so  near  it 
that  the  shock  of  the  operation  must  inevitably  prove  fatal. 
They  believe  that  the  promptest  possible  operation  is  in  nearly 
all  cases  the  truest  conservatism. 

i 

2.  The  Conservative  Surgical  Method. — This*  seems  to  be 
favored  by  a  majority  of  all  the  well-known  surgeons  of  the 
United  States  and  of  the  world,  including  Richardson  of 
Boston,  Wyeth  of  New  York,  Park  of  Buffalo,  and  in  Phila- 
delphia the  following  authors  of  works  on  surgery  or  gyne- 
cology: Keen,  White,  Martin,  Willard,  Montgomery,  and  Da 

743 


744  THE    GASTRO-INTESTINAL    CLINIC 

Costa,  and  a  long  list  of  others,  besides  prominent  surgeons, 
too  numerous  to  mention,  in  all  the  large  cities. 

This  method  differs  from  the  radical  one  mainly  in  de- 
ferring operation  under  certain  conditions — especially  in  most 
cases  not  seen  early — until  after  the  acute  attack  has 
ended,  and  then  doing  in  most  instances  the  very  much  safer 
interval  operation.  The  conditions  which  should  lead  to  a 
postponement  of  operation,  and  a  dependence  for  the  time 
upon  other  measures,  vary  considerably  with  the  different 
surgeons.  Most  of  them  agree  in  not  advising  operation  dur- 
ing the  acute  stage  after  the  second  day,  or  rather  after  the 
disease  has  progressed  beyond  the  appendix  itself,  unless  there 
is  a  walled-off  abscess,  or  unless  perforation  or  gangrene  has 
resulted.  Many  of  them,  also,  prefer  to  trust  to  nature  and 
non-operative  methods  of  treatment  in  the  milder  catarrhal 
cases,  even  when  these  are  seen  early. 

When  they  withhold  the  knife,  the  numerous  conservative 
surgeons  differ  again  considerably  in  their  therapeutic  meas- 
ures, but  most  of  them  keep  the  bowels  open  by  means  of 
calomel  or  salines,  and  feed  lightly  with  liquid  diet,  though 
Richardson  seems  to  have  adopted,  for  cases  in  which  opera- 
tion must  be  deferred,  the  Ochsner  practice  of  washing  out  the 
stomach,  prohibiting  ph3^sic,  and  allowing  no  food  by  the 
mouth.  Probably  some  of  the  others  have  recently  modified 
their  methods  in  like  manner. 

Nearly  all  employ  emollient  or  revulsive  local  applications 
including  poultices  or  wet  compresses  as  hot  as  can  be  borne, 
or,  in  the  more  severe  cases,  rely  upon  ice  locally.  Most  advise 
only  a  very  sparing  use  of  opiates,  when  necessary  for  severe 
pain. 

3.  The  Ochsner  Plan,  or  Surgico- Starvation  Method,  is 
radically  surgical  in  the  main,  but  combines  the  practice  of 
the  so-called  conservative  surgeons  in  some  respects,  along 
with  a  most  rigorous  withholding  from  the  upper  gastro-in- 
testinal  tract  of  anything,  either  food  or  medicine,  which  could 
produce  peristaltic  action.     Ochsner  of  Chicago    first  began 


TREATMENT    OF    APPENDICITIS  745 

putting  it  systematically  into  effect  about  the  year  1898,  and 
it  has  already  attracted  wide  attention.  He  is  a  believer  in 
the  doctrine  that  every  case  of  appendicitis  should  be  operated 
at  some  time,  but  holds  that  it  makes  a  vast  difference  in  the 
results  at  what  stage  of  a  case  the  operation  is  done.  He  in- 
sists that  every  case,  no  matter  how  mild,  should  be  operated 
when  the  opportunity  is  afforded  to  do  this  during  the  first 
thirty-six  hours,  or  at  least  before  the  disease  has  progressed 
beyond  the  appendix  itself,  but  that  when  this  cannot  be  done, 
it  is  best  to  wait  until  the  attack  has  entirely  passed  over, 
unless  during  the  acute  stage  there  should  be  developed  a 
circumscribed  abscess,  when  this  may  be  opened  and  emptied. 
When  gangrene  or  perforation  has  occurred,  he  particularly 
objects  to  operation,  believing  this  to  be  more  dangerous 
then  than  waiting,  provided  his  rest  and  starvation  method  is 
strictly  carried  out. 

Acting  on  the  theory  that  the  danger  in  appendicitis  is 
chiefly  in  the  spread  of  the  infection  to  the  entire  peritoneal 
cavity  with  the  result  of  a  general  diffused  peritonitis,  which 
often  follows  an  operation  in  an  advanced  case  of  acute  ap- 
pendicitis, Ochsner  enforces  absolute  rest  of  the  body,  and  of 
the  gastro-intestinal  functions  in  particular,  by  first  washing 
out  the  stomach  with  plain  water  or  normal  salt  solution,  to 
remove  any  remains  of  a  previous  meal,  and  then  prohibiting 
absolutely  all  food  by  the  mouth  as  well  as  the  administra- 
tion of  any  remedies  such  as  cathartics,  which  could  excite 
peristaltic  action. 

It  will  be  obviously  fairer  to  him  to  let  him  describe  his 
method  in  his  own  words,  and  I  therefore  quote  the  following 
from  his  latest  paper  :^ 

Ochsner's  Description  of  His  Method. — "  In  every  case  of 
acute  appendicitis  entering  the  hospital,  all  food  by  mouth  and 
all  cathartics  were  prohibited.  In  case  the  patient  suffered 
from  nausea  or  vomiting,  gastric  lavage  was  at  once  employed. 
In  the  milder  cases  the  patient  was  permitted  to  rinse  the 
'  Med.  News,  May  2,  1903. 


746  THE    GASTRO-INTESTINAL    CLINIC 

mouth  with  cold  water  and  to  drink  small  sips  of  very  hot 
water  at  short  intervals.  In  the  severer  cases  the  patient  was 
pe!tmitted  to  rinse  the  mouth  with  cold  water,  but  was  not  per 
mitted  to  drink  either  hot  or  cold  water  for  the  first  few  days 
until  the  acute  attack  had  subsided,  when  the  use  of  small  sips 
of  hot  water  was  begun.  If  the  nausea  persisted,  gastric  lav- 
age was  repeated  once  or  twice  at  intervals  of  two  to  four 
hours,  in  order  to  remove  any  substance  which  had  regurgi- 
tated into  the  stomach  from  the  small  intestines. 

"  The  patient  was  supported  by  nutrient  enemata  consist- 
ing of  an  ounce  of  one  of  the  concentrated  predigested  liquid 
foods  in  the  market,  dissolved  in  three  ounces  of  warm  normal 
salt  solution  introduced  through  a  catheter,  which  was  in- 
serted a  distance  of  two  and  one-half  to  three  inches.  In  case 
this  gave  rise  to  pain  or  irritation  or  nausea,  it  was  interrupted 
for  twelve  to  twenty- four  hours  at  a  time.  In  cases  in  which  no 
water  was  given  by  the  mouth,  an  enema  of  eight  ounces  of 
normal  salt  solution  was  given  four  to  six  times  a  day,  in  ad- 
dition to  the  nutrient  enemata.  In  cases  operated  during 
the  acute  attack,  this  treatment  was  continued  for  several  days 
after  the  operation. 

"  After  the  patient  had  been  free  from  pain,  and  otherwise 
practically  normal  for  four  days,  he  was  first  given  from  one 
to  four  ounces  of  weak  beef  tea,  preferably  prepared  from 
commercial  beef  extract,  every  two  hours.  In  a  few  days  one 
of  the  commercial  predigested  foods,  dissolved  in  water,  was 
substituted;  still  later,  equal  parts  of  milk  and  limewatcr;  then 
general  licjuids ;  then  light  diet,  and  finally,  after  the  patient  had 
fully  recovered,  full  diet  was  given.  The  commercial  extract 
of  beef  was  chosen  because  it  contains  only  soluble  material, 
which  will  usually  be  absorbed  from  the  stomach  without 
giving  rise  to  peristalsis.  The  rectal  feeding  was  continued 
in  the  mean  time.  By  following  this  plan  the  patient  is  sat- 
isfied, and  one  is  less  likely  to  do  harm  with  this  than  any 
other  form  of  food.  Of  course,  the  benefit  to  the  patient  is 
chiefly  imaginary. 


TREATMENT    OF   APPENDICITIS  747 

"  So  far,  nothing  has  been  said  of  the  operative  treatment, 
intentionally,  because  the  treatment  I  have  just  described  was 
applied  to  all  cases  of  acute  appendicitis,  without  regard  to  the 
severity  of  the  case  or  the  stage  at  which  the  patient  was  ad- 
mitted to  the  hospital.  Moreover,  because  this  is  the  part  of 
the  treatment  which  is  responsible  for  the  enormous  reduction 
in  the  mortality. 

"  Operative  Treatment. — The  rule  which  was  followed  as 
regards  the  time  of  operation  varied  with  the  individual  cases. 
In  any  given  case,  the  operation  was  performed  at  the  time  the 
patient  entered  the  hospital,  or,  if  this  occurred  at  night,  on 
the  following  morning,  provided  it  seemed  clear  from  the 
condition  of  the  patient  that  he  would  recover  if  the  operation 
were  performed  at  once,  judging  from  my  own  experience  in 
similar  cases  treated  in  the  past.  This  could  usually  be  ex- 
pected in  severe  cases  admitted  before  the  end  of  thirty-six 
hours  from  the  beginning  of  the  attack,  and  in  the  milder  cases 
during  a  longer  period. 

"  In  all  cases  in  which  the  recovery  seemed  at  all  doubtful, 
the  operation  was  postponed  and  the  patient  was  placed 
under  the  treatment  described  above,  until  the  acute  condition 
had  subsided.  In  some  of  these  cases  it  became  necessary  to 
open  a  circumscribed  abscess,  and  later  to  make  a  second  opera- 
tion for  the  removal  of  the  appendix.  In  other  cases  the  in- 
flammation became  circumscribed,  and  the  appendix  could  be 
safely  removed,  the  pus  sponged  out  of  the  circumscribed  ab- 
scess, the  abdominal  wound  could  be  closed,  a  drain  being  in- 
troduced through  a  small  incision  two  inches  externally  to  the 
abdominal  incision." 

The  foregoing  is  a  plain  and  fair  statement  of  the  different 
methods  practiced,  and  of  the  points  at  issue  between  them. 
The  latter  ought  to  be  decided  in  an  entirely  dispassionate 
way,  the  same  as  any  other  purely  scientific  question,  without 
the  slightest  regard  to  any  consideration  except  the  interests 
of  the  patients  whose  lives  are  at  stake.  I  have  given  the 
matter  much  thought  and  study,  feeling  that  the  words  of  an 


748  THE    GASTRO-INTESTINAL    CLINIC 

author  upon  any  such  important  subject  should  be  very  care- 
fully weighed. 

Murphy's  Method — Since  the  earlier  editions  of  this  book 
appeared,  Dr.  John  B.  Murphy  of  Chicago  has  written  for 
Keen's  Surgery  an  article  on  Appendicitis,  in  which,  while 
agreeing  with  most  other  abdominal  surgeons  as  to  the  advis- 
ability of  early  operati\'e  intervention  in  this  disease,  he  ad- 
vocates operating  in  a  somewhat  novel  way  in  the  suppura- 
tive cases  complicated  by  acute  general  peritonitis.  He  holds 
to  the  familiar  doctrine  that  the  most  favorable  time  for 
operating  is  in  the  first  thirty-two  hours,  before  perforation 
with  infection  of  the  periappendical  tissues.  On  this  head  he 
says:  "The  danger  of  intervention  in  the  early  stage  is 
scarcely  more  than  that  of  an  exploratory  laparotomy.  The 
time  required  for  the  convalescence  is  not  more  than  two  and 
a  half  to  three  weeks.  *  ^=  *  The  patient  would  be  relieved  of 
his  appendicitis  without  hazard,  without  prolonged  illness, 
without  danger  of  unpleasant  sequelae,  and  without  the  pos- 
sibility of  recurrence  by  the  timely  operation." 

When  perforation  has  already  occurred,  Murphy,  unlike  the 
more  conservative  surgeons,  advises  operative  intervention, 
but  with  certain  precautions  which  render  it  much  safer  than  it 
was  formerly  under  such  circumstances.  He  insists  that  the 
intestines  should  then  be  all  walled  off  with  gauze  packing,  that 
the  agglutinations  of  the  abscess  wall  "  be  separated  with  the 
fingers,  sufficient  pus  removed  to  permit  inspection  of  the 
cavity,  and,  if  easily  recognized,  or  if  not  more  than  four  days 
have  elapsed  since  the  onset  of  the  disease,  the  appendix  should 
be  searched  for  and  removed." 

In  general  suppurative  peritonitis  due  to  a  perforation  of  the 
appendix  or  rupture  of  a  circumscribed  appendical  abscess  into 
the  free  peritoneal  cavity,  Murphy  still  advocates  operation, 
but  in  a  most  careful  and  cautious  manner  thus  de- 
scribed :  He  opens  the  abdomen  as  in  primary  appendicitis, 
and  amputates  the  appendix  to  prevent  further  leakage.  Then 
he  inserts  a  rubber  drain  to  the  stump  and  another  to  the  base 


TREATMENT  OF  APPENDICITIS  749 

of  the  vesico-rectal  or  Douglas  pouch,  but  avoids  all  manipula- 
tion of  the  intestine  and  sponging  or  flushing  of  the  perito- 
neum for  the  removal  of  the  pus,  and  closes  the  abdominal  in- 
cision, often  with  pints  of  pus  remaining  in  the  cavity.  The 
operation,  then,  must  be  the  shortest  possible,  rarely  needing 
to  exceed  ten  minutes.  He  then  puts  the  patient  in  the  extreme 
Fowler's  (sitting)  position,  and  institutes  proctoclysis  by  in- 
jecting into  the  rectum  every  two  hours  one  and  a  half  pints 
of  the  normal  salt  solution  together  with  a  pint  and  a  half  of  a 
calcium  chloride  solution,  one  dram  to  the  pint.  In  the 
severely  septic  cases  he  advocates  the  addition  to  the  treatment 
of  20  c.c.  of  streptolytic  serum,  particularly  in  the  cases  having 
a  low  leucocytosis,  repeating  this  twice  in  twenty-four  hours 
till  the  symptoms  subside.  The  proctoclysis,  detailed  direc- 
tions for  which  are  given  in  Keen's  Surgery,  page  788,  is 
generally  continued  for  three  days,  and  exceptionally  for  five 
or  six  days.  Murphy  reports  40  consecutive  cases  of  peri- 
tonitis treated  on  this  plan  with  only  two  deaths,  an  ex- 
traordinary improvement  over  the  results  formerly  obtained 
by  even  the  most  skilled  operators. 

The  Results  Must  Decide. — Obviously  the  decision  as  to 
which  of  various  methods  of  treatment  is  best  in  any  disease, 
must  depend  upon  the  relative  results  achieved  under  each  of 
them.  So  it  must  be  in  deciding  what  method  of  treating  ap- 
pendicitis is  to  be  preferred.  That  one  which  will  save  the 
largest  proportion  of  lives  will,  of  course,  be  finally  accepted. 
Though  it  is  true  that  figures  can  sometimes  be  made  to  lie, 
the  statistics  as  to  the  results  in  a  sufficiently  large  aggregate 
of  cases  must  ultimately  decide  all  such  questions. 

In  addition  to  the  figures  given  under  the  head  of  Prognosis, 
in  the  preceding  lecture,  the  following,  embracing  the  results 
of  several  prominent  surgeons  who  dififer  in  their  views  re- 
garding the  time  to  operate  in  appendicitis,  will  shed  some 
light  upon  the  subject : 

Richardson's  Results  in  1903. — Dr.  M.  H.  Richardson  of 
Boston,  who  is  one  of  the  most  eminent  of  those  surgeons 


750  THE    GASTRO-INTESTINAL    CLINIC 

whom  I  have  classed  above  as  "  conservative,"  has,  in  answer 
to  an  inc|uiry  from  me,  submitted  the  following  report  under 
(?ate  of  January  7,  1904: 

Total  number  of  cases  operated  on  in  1903 149 

Acute 44 

Chronic 105 

"  In  the  44  acute  cases  there  were  two  deaths,  both  from 
general  peritonitis.     In  these  cases  recovery  was  not  expected." 

He  added  that  he  could  not  say  how  many  cases  of  general 
peritonitis  there  were,  but  had  never  in  his  experience  known 
a  fully  developed  case  of  the  kind  to  recover. 

Dr.  Richardson's  mortality  rate  in  acute  cases  figured  out 
4.54  per  cent. ;  in  chronic  cases  o. 

Dr.  W.  Wayne  Babcock,  the  Surgeon-in-Chief  of  the  Sa- 
maritan Hospital,  Philadelphia,  wrote  me  a  personal  com- 
munication under  date  of  December  17,  1903,  embodying  a 
report  of  his  results  in  operations  for  appendicitis.  Up  to  that 
time  he  had  had  no  deaths  in  either  interval  operations  or  in 
those  done  during  the  first  forty-eight  hours — none,  in  fact, 
except  in  the  cases  complicated  by  general  peritonitis,  which 
then  was  very  generally  fatal. 

The  following  further  statistics  covering  the  work  of 
Deaver  in  the  year  ended  September  i,  1903,  and  Ochsner's 
last  566  cases  previous  to  December,  1903,  are  of  great  inter- 
est, not  only  as  demonstrating  the  extraordinary  advances 
made  in  lessening  the  mortality  of  appendicitis  by  the  chief 
exponents  of  two  different  methods  of  treating  it,  but  also 
as  showing  the  comparative  results  of  these  different  methods 
— the  one  depending  on  non-operative  measures  in  most  cases 
during  the  serious  stage,  and  even  in  the  gravest  complications, 
and  the  other  relying  upon  the  aseptic  knife  and  deft  fingers 
of  the  expert  surgeon,  operating  nearly  always,  early  if 
])Ossible,  but  if  not,  then  operating  anyway,  as  a  rule  (to  which 
he  makes  some  exceptions),  in  accordance  with  the  view  that 
this  affords  the  patient  the  best  chance  of  recovery. 

Deaver's  Recent  Work — Dr.   Deaver,  in  a  paper  entitled 


TREATMENT  OF  APPENDICITIS  75  I 

One  Year's  Work  in  Appendicitis/  reported  his  operations 
from  September  i,  1902,  to  September  1,  1903,  as  follows: 

16  cases  with  general  peritonitis  with  5  deaths  ;  mortality 31  per  cent. 

183  acute  cases  with  abscess,  22  deaths  ;  "  . . .  .12     "      " 

194  acute  cases  without  abscess,  3  deaths  ;  "  1|     "      " 

173  cases  of  chronic  appendicitis,  o  deaths  ;  "  ....  o     "      " 

In  a  personal  note  to  the  author,  written  May   17,   1910, 

Dr.   Deaver  reports  that   in  the  previous   six  years   he  had 

operated  upon  3824  cases  of  appendicitis  with  a  mortality  of 

43/2  per  cent.     In  chronic  cases  his  mortality  during  the  same 

.period  was  0.3  per  cent. 

Ochsner's  Last  566  Cases. — Ochsner,  in  response  to  a  re- 
quest for  his  latest  statistics,  wrote  me  under  date  of  December 
5,  1903,  that  the  results  of  treatment  in  the  last  566  cases 
treated  by  him  in  the  Augustana  Hospital,  Chicago,  up  to  that 
date,  were  as  follows  : 

Number  of  cases  of  appendicitis  with  general  peritonitis,  15  ; 

recovered,  9  ;  died,  6. ;  mortality 40  per  cent. 

Number  of  cases  of  acute  appendicitis  with  abscess.  81  ; 

recovered,  80  ;  died,  1  ;  mortality 1^  per  cent. 

Number  of  cases  of  acute  appendicitis  without  abscess,  173  ; 

recovered,  170  ;  died,  3  ;  mortality if  per  cent. 

Number  of  chronic  and  interval  cases,  297  ; 

recovered,  295  ;  died,  2  ;  mortality f  per  cent. 

Under  date  of  May  21,  1910,  he  writes:  "My  hospital 
statistics  during  the  past  year  show  a  trifle  less  than  2  per  cent, 
mortality  in  all  of  the  cases  of  perforated,  gangrene,  and  sup- 
purative peritonitis;  no  mortality  in  cases  which  come  under 
treatment  before  the  end  of  36  hours  from  the  beginning  of 
an  acute  attack,  and  no  mortality  in  cases  of  interval  opera- 
tions." 

Deductions  from  the  Foregoing  Statistics. — From  the  above 
array  of  statistics  a  few  very  interesting  and  highly  important 
inferences  are  clearly  deducible : 

I.  The  most  expert  abdominal  surgeons,  when  surrounded 
by  the  assistants  and  appliances  of  their  own  hospitals,  can 
^Am.  Med.,  October  17,  1903, 


752  THE    GASTRO-INTESTINAL    CLINIC 

Operate  hopefully  upon  almost  any  case  of  appendicitis  at  any 
stage.  In  the  chronic  form  of  the  disease  they  very  rarely 
now  lose  a  case.  In  any  acute  case  operated  during  the  first 
thirty-six  hours  their  mortality  is  extremely  low — next  to 
none — and  even  at  a  later  stage  of  the  ordinary  acute  cases, 
when  general  peritonitis  has  not  developed,  the  figures  are  still 
very  favorable.  Deaver's  194  simple  acute  cases,  with  only  3 
deaths — 1.5  per  cent — make  a  remarkable  showing.  Though 
in  a  much  smaller  number  of  cases,  Babcock's  total  absence  of 
mortality,  in  all  cases  except  those  complicated  by  general  peri- 
tonitis, was  exceedingly  creditable. 

The  latest  figures  reported  up  to  May,  19 10,  by  both  Deaver 
and  Ochsner  can  only  be  characterized  as  extraordinary. 

2.  Regarding  perforative  or  gangrenous  appendicitis,  and 
those  cases  in  which  general  peritonitis  exists,  the  statistics  so 
far  reported  leave  some  doubt  whether  the  generally  accepted 
surgical  plan  of  operating  at  the  earliest  possible  moment  after 
the  discovery  of  the  condition  is  able  to  save  as  large  a  pro- 
portion of  lives  as  can  be  saved  by  the  Ochsner  method  already 
described,  even  when  the  operation  can  be  done  under  the  ex- 
ceptionally favorable  conditions  above  mentioned,  and  with 
the  improved  technique  recommended  by  Murphy.  When  the 
operation  must  be  done,  if  at  all,  by  a  surgeon  not  indubitably 
of  the  very  highest  skill,  or  under  conditions  unfavorable  in 
any  other  respect  additionally  to  the  serious  form  of  the  dis- 
ease, there  can  be  no  question  that  the  Ochsner  method  would 
promise  best,  especially  if  the  previous  treatment  had  not  in- 
volved the  administration  of  food  by  the  mouth. 

The  judgment  and  experience  of  at  least  one  eminent  surgeon 
— and  numerous  other  able  surgeons  now  agree  with  him — 
have  come  to  reinforce  the  matured  views  of  most  hygienists 
and  conservative  internists  to  the  effect  that  a  little  fasting  now 
and  then  can  help  save  life  at  critical  junctures,  when  the  sys- 
tem has  neither  the  energy  to  digest  and  assimilate  food  nor 
to  excrete  it  undigested. 

It  is  a  fair  inference  that  perfect  rest  and  the  starvation 


1 


TREATMENT  OF  APPENDICITIS  753 

plan  will  rescue  a  larger  proportion  of  the  more  dangerous 
forms  of  the  acute  cases  after  the  first  48  hours,  or  after  the 
peritoneum  has  become  infected,  than  operation,  by  even 
the  very  best  abdominal  surgeons.  At  least  this  seems  to  be 
true  as  regards  the  latest  statistics  of  the  two  methods  which 
are  obtainable ;  but  the  surgeons  are  constantly  improving  their 
technique  and  lowering  the  mortality  rate,  and  it  is  by  no  means 
impossible  that  the  statistics  for  some  future  year  may  tell  a 
different  story. 

3.  The  belief  that  almost  any  sort  of  surgery  is  safer  in 
acute  appendicitis  than  the  very  best  possible  non-operative 
treatment  is  no  longer  defensible.  It  has  been  gaining  ground 
rapidly  of  late,  both  in  the  medical  profession  and  among  the 
laity.  I  do  not  think  it  was  ever  quite  true.  In  the  country 
districts,  and  everywhere  remote  from  the  larger  cities,  where 
alone  really  skilled  and  experienced  abdominal  surgeons  are  to 
be  found,  as  a  rule,  the  Ochsner  method  should  clearly  be  pre- 
ferred, operation  being  deferred — in  all  cases,  at  least,  in 
which  an  operation  cannot  be  done  during  the  first  two  days — 
until  after  full  convalescence,  when  an  operator  of  even 
ordinary  ability  and  experience  could,  with  reasonable  safety, 
undertake  the  task  of  removing  the  appendix,  provided  he  had 
mastered  the  technique  of  abdominal  sections. 

4.  The  most  obvious  and  important  inference  to  be  made 
from  the  foregoing  statistics  is  that  no'  patient  threatened 
with  acute  appendicitis,  or  with  any  disease  resembling  it, 
should  be  given  even  the  slightest  amount  of  food  by  the 
mouth  till  all  danger  of  suppuration  has  passed,  and  no  pur- 
gative or  laxative  medicine,  except  when  the  patient  is  seen 
early  enough  to  admit  of  the  bowels'  being  cleared  out  safely 
before  pus  could  have  had  time  to  form  in  the  appendix. 

This  would  be  a  safe  rule  for  all  such  cases,  regardless  of 
what  the  after-treatment  might  be.  Even  if  operative  inter- 
vention were  to  be  resorted  to  later,  the  patient's  chances  would 
be  improved  by  such  a  preliminary  treatment,  and  if  a  skilled 
surgeon  could  not  be  obtained  in  time,  a  life  that  might  other- 


754  THE    GASTRO-INTESTINAL    CLINIC 

wise  have  been  sacrificed    would  probably  then  be  saved  by- 
continuing  strictly  the  Ochsner  method. 

A  Symposium  on  Appendicitis. — As  editor  of  the  Interna- 
tional Medical  Magazine  I  arranged  for  a  symposium  on  ap- 
pendicitis in  that  journal  for  November,  1901,  and  received 
papers  or  answers  to  questions  upon  the  subject  from  sixteen 
prominent  authorities.  Ten  of  them,  viz.,  Wyeth,  Park, 
Morris,  Ochsner,  Murphy,  Willard,  Martin,  Richardson, 
Turck,  and  Stockton,  nine  of  whom,  including  all  but  the  last 
named,  were  surgeons,  answered  specifically  the  following 
question :  "  Generally  speaking,  what  mode  of  treatment  do 
you  advise  during  the  first  two  days  of  a  mild  or  moderately 
severe  attack  of  appendicitis  ?  "  Of  these  ten  answers,  three 
unqualifiedly  favored  operation  under  the  conditions  named, 
these  coming  from  Morris,  Murphy,  and  Ochsner.  The  last 
named,  while  advocating  operative  intervention  in  the  first  two 
days  in  all  cases  when  a  competent  surgeon  can  be  obtained, 
opposed  operation  in  perforation  or  gangrene.  His  answer  as 
to  the  preferable  treatment  in  an  acute  case,  after  the  beginning 
of  the  third  day,  was  as  follows :  "  Exclusive  rectal  feeding, 
no  nourishment  of  any  kind  nor  cathartics  by  the  mouth ; 
gastric  lavage.  If  this  is  done,  the  condition  will  not  gTow 
worse." 

Seven  of  the  answers  above  mentioned,  all  but  one  from  men 
who  have  had  experience  in  making  abdominal  sections,  ad- 
vocated relying  upon  some  form  of  non-operative  treatment 
during  the  first  two  days  of  a  mild  or  moderately  severe  attack 
of  appendicitis,  though  several  of  them  spoke  of  being  in 
readiness  to  operate  in  the  event  of  threatening  symptoms. 
Including  Ochsner,  then,  eight  of  the  ten  writers  who  an- 
swered the  questions  favored  a  reliance  upon  medical  meas- 
ures either  during  the  first  stage  of  a  mild  attack,  or  during 
the  acute  stage  after  the  first  two  days,  whenever  there  are  in- 
dications that  the  infection  has  extended  beyond  the  appendix 

itself. 

Richardson's  Conservative  View. — Richardson,  in  the  quite 


TREATMENT    OF    APPENDICITIS  755 

recent  lecture  by  him  already  cited,  says :  "  My  own  views 
briefly  are  that  operation  is  indicated  in  most,  if  not  all  severe 
cases  [italics  ours]  when  first  seen,  unless  the  symptoms  are 
unquestionably  improving,  or  unless  the  patient  is  hopelessly 
moribund.  In  many  cases  of  moderate  severity  I  wait  for 
complete  subsidence  of  the  infection,  as  in  the  present  case, 
before  opening  the  abdomen."  Again,  in  the  same  lecture,  he 
says :  "  When  it  is  clear  that  operation  will  take  away  the  only 
chance  that  the  patient  has,  I  refrain  from  intervention,  trust- 
ing to  gastric  lavage  and  rectal  feeding,  as  suggested  by 
Ochsner."  The  champion  of  absolute  rest  for  both  the  body 
generally  and  the  peristaltic  apparatus  in  particular,  from  the 
very  beginning  of  the  treatment,  might  reply  to  the  last  sen- 
tence above  quoted,  that  cases  which  have  been  regularly  fed 
by  the  mouth  from  the  outset,  and  purged  freely  in  addition, 
could  hardly  be  saved  by  the  adoption  of  his  method  at  the 
last,  after  their  condition  has  become  too  desperate  for 
operation. 

The  Treatment  of  Acute  Catarrhal  Appendicitis. — The 
treatment  which  I  have  found  successful  in  acute  catarrhal 
appendicitis  consists  of  rest  in  bed,  and  when  possible,  in  a 
cheerful,  well-lighted,  and  well-ventilated  room,  the  application 
of  hot  mush  or  flax-seed  meal  poultices  over  the  affected  re- 
gion, every  two  or  three  hours,  or  oftener  when  the  oain  is 
very  severe,  and  the  administration  of  calomel  in  i-io  grain 
doses  every  two  hours,  night  and  day,  till  the  bowels  respond 
by  one  or  two  soft  yellow  stools — not  until  it  produces  free 
purgation,  and  not  followed  by  saline  cathartics  to  effect  such 
a  result.  The  calomel  given  in  this  way  has  always  seemed  to 
assist  markedly  in  removing  all  symptoms  of  the  disease,  and 
the  cures  thus  effected  have  comparatively  infrequently  in  my 
experience  been  followed  by  any  return  of  the  trouble.  In 
view  of  Ochsner's  extraordinary  results  I  should  ndw  advise 
the  utmost  caution  in  the  employment  of  even  the  small  doses 
of  calomel  above  mentioned,  and  limit  the  use  of  the  remedy 
to  the  earliest  stage  of  the  milder  cases  not  likely  to  develop 


75^  THE    GASTRO-INTESTINAL    CLINIC 

suppuration,  or  to  the  very  beginning  of  severe  ones.  As  to 
diet,  my  own  experience  in  this  class  of  cases  has  been  with  a 
very  restricted  and  simple  diet  consisting  of  small  quantities 
of  broth  or  beef  juice,  or  whites  of  eggs,  and  a  little  milk  or 
gruel.  Again  profiting  by  Ochsner's  experience,  and  in  view 
of  the  fact  that  even  the  milder  catarrhal  cases  may  excep- 
tionally take  on  later  a  severe  form,  I  now  advise  feeding  by 
the  rectum  exclusively  in  all  cases  of  appendicitis  until  the 
danger  is  entirely  over,  since  there  is  no  difficulty  in  maintain- 
ing nutrition  by  this  method  for  the  short  period  necessary, 
especially  in  the  case  of  a  person  strictly  confined  to  bed,  and 
nothing  is  then  put  into  the  upper  part  of  the  alimentary  canal 
to  provoke  peristalsis.  It  is  furthermore  a  valuable  precaution 
to  wash  out  the  stomach  at  the  start  so  as  to  prevent  danger 
from  the  food  previously  taken. 

In  the  beginning  of  the  attack,  and  especially  when  there 
has  been  constipation  previously,  the  colon  should  be  unloaded 
by  flushing  with  either  a  normal  salt  solution  or  soapy  water, 
or  what  is  safer  whenever  the  temperature  is  at  all  high  and 
suppuration  is  to  be  feared,  by  repeated  injections  of  olive 
or  cotton-seed  oil,  which  will  usually  effect  the  object  almost 
as  surely,  if  not  C[uite  so  promptly,  and  without  irritation.  At 
the  same  time  i-ioo  to  1-50  grain  of  atropine  may  be  injected 
hypodermically,  and  be  repeated  cautiously  till  its  constitu- 
tional effects  have  been  obtained,  when  necessary  to  relax 
spasm  and  promote  evacuation,  especially  in  case  the  dif- 
ficulty of  procuring  a  stool  seems  due  to  a  spastic  condition. 

Large  disturbing  enemas  as  a  means  of  emptying  the  colon 
should  not  be  employed,  in  my  opinion,  whenever  there  are 
evidences  of  peritonitis,  either  local  or  general,  since  only 
harm  can  result  from  opposing  in  any  manner  nature's  con- 
servative efforts  to  prevent  peristalsis  in  such  conditions. 
When  the  above-mentioned  milder  injections  fail,  though  it  be 
apparently  in  an  early  stage  only  of  the  attack,  and  no  peri- 
tonitis is  believed  to  have  yet  developed,  do  not  try  to  force 
bowel  movements  by  stronger  or  more  irritating  ones  lest 


TREATMENT    OF    APPENDICITIS  757 

peritonitis  should  have  begun,  even  though  not  yet  demon- 
strable. I  still  remember  very  vividly  my  appendicitis  cases 
of  twenty  to  twenty-five  years  ago,  then  called  typhlitis  or 
perityphlitis,  and  especially  how  every  attempt  to  force  bowel 
movements  even  by  enemas  aggravated  the  inflammation  and 
fever,  turning  the  scale  against  the  patient  sometimes,  when 
before  things  were  progressing  favorably. 

In  cases  more  severe  with  a  temperature  running  up  to 
102°  or  higher,  and  acute  tenderness  over  a  larger  area,  ice 
bags  or  an  ice  coil  may  prove  more  efifective  than  hot  applica- 
tions-and  a  little  opium  may  be  found  necessary  to  blunt  the 
pain,  but  the  latter  remedy  should  never  be  pushed  to  the  point 
of  complete  narcosis,  since  this  would  greatly  obscure  the 
progress  of  the  case,  and  add  to  the  dangers  of  the  patient. 
When  such  marked  symptoms  occur  early — within  the  first 
thirty-six  hours — they  raise  the  suspicion  that  the  attack  is  to 
be  more  than  a  simple  catarrhal  one,  and  would  warrant  your 
calling  a  surgeon  in  consultation  to  consider  the  propriety  of 
an  operation  while  yet  the  disease  is  limited  to  the  appendix — 
or  at  least  to  a  circumscribed  abscess.  Much  better  than  a 
free  use  of  any  opiate  is  a  reliance  in  part  upon  belladonna  or 
atropine,  which  possesses  valuable  antispasmodic  properties, 
and  should  be  particularly  effective  in  relieving  pain  due  to 
the  spasmodic  closure  of  the  appendix  at  its  cecal  end,  or  to 
complicating  colics  in  other  parts  of  the  intestines  resulting 
from  like  spastic  conditions. 

Treatment  of  the  Severer  Forms  of  Acute  Appendicitis. — 
In  cases  which  begin  in  a  severe  and  threatening  way  (ful- 
minant cases)  operation  during  the  first  thirty-six,  and  pos- 
sibly during  the  first  forty-eight  hours,  promises  better  results 
than  any  medical  measures,  always  provided  that  a  thoroughly 
expert  laparotomist  can  be  had,  and  that  in  other  respects  the 
conditions  are  such  that  a  perfectly  aseptic  operation  can  be 
done.  If  the  patient  occupies  a  dirty  room  far  from  any 
hospital,  and  cannot  command  the  services  of  both  a  skilled 
surgeon  and  trained  surgical  nurse,  the  advantages  of  opera- 


758  THE    GASTRO-INTESTINAL    CLINIC 

tion  during  the  height  of  the  attack  compared  with  rest  in 
bed^  abstinence  from  food  and  drink  by  the  mouth,  as  well  as 
from  purgative  medicines,  and  the  help  of  other  appropriate 
measures,  would  be  more  than  doubtful.  In  any  case  not 
diagnosticated  until  after  the  first  thirty-six  hours,  you  will, 
as  a  general  rule,  to  which  there  are  few  exceptions,  be  safe  to 
advise  against  operation  until  after  the  subsidence  of  the 
acute  stage,  provided  the  method  by  enforcing  complete  absti- 
nence from  stomach  feeding  and  purgatives  be  strictly  carried 
out.  One  of  the  few  exceptions  would  be  cases  in  which  a 
circumscribed  abscess  has  formed,  which  can  be  opened  easily 
without  danger.  But  in  every  severe  case  of  acute  appendicitis 
it  is  a  wise  precaution  to  have  a  surgeon  in  consultation  until 
the  danger  point  has  been  passed. 

Whatever  views  one  may  hold  as  to  the  time  for  operation 
in  these  cases  when  suppuration  exists  or  is  threatened,  it 
must  be  admitted  that  non-operative  treatment  is  often  the 
only  kind  practicable,  for  the  reason  that  the  patient  refuses 
to  have  the  operation  done,  or  because  it  is  impossible  to  ob- 
tain, in  time,  a  surgeon  possessed  of  sufficient  skill  and  ex- 
perience to  do  it  with  the  prospect  of  any  more  favorable  re- 
sults than  would  follow  the  best  medical  treatment.  Further- 
more, when  the  diagnosis  has  not  been  made  or  the  consent  of 
the  patient  and  family  obtained  to  an  operation  until  after  the 
second  day,  and  a  circumscribed  tumor  has  not  yet  been 
formed,  non-operative  measures  are  to  be  preferred  till  the 
acute  stage  has  passed,  or  a  walling  in  of  the  abscess  been 
fully  accomplished.  Under  these  circumstances  you  should 
pursue  the  same  course  advised  already  for  the  mild  catarrhal 
form,  except  that  under  no  circumstances  should  anything, 
either  food,  drink,  or  medicines,  be  given  by  the  mouth  which 
could  tend  to  excite  peristalsis — i.  e.,  no  stomach  feeding,  no 
drinking,  and  no  cathartics  or  laxatives  at  all.  Dr.  R.  G. 
Curtin  of  Philadelphia  reports  excellent  results  from  the  ap- 
plication of  a  blister  over  the  cecum  in  the  beginning  of  acute 
appendicitis. 


TREATMENT    OF    APPENDICITIS  759 

The  Treatment  of  Chronic  Catarrhal  Appendicitis. — Here 
again,  I  must  take  issue  with  the  more  radical  of  the  surgeons, 
as  well  as  with  Ochsner,  and  advise  against  the  hard  and  fast 
rule  that  all  cases  without  exception  which  have  shown  indica- 
tions of  a  slight  involvement  of  the  appendix  in  a  catarrhal 
process  should  be  operated.  I  have  seen  such  cases  get  ap- 
parently well  under  medical  treatment,  and  the  easily  palpated, 
thickened  appendix  subside  to  its  normal  size  while  its  tender- 
ness on  palpation  disappeared.  It  is  granted  that  other  cases 
not  under  strict  treatment  recur  again  and  again,  and  often 
finally  in  a  serious  form  which  proves  fatal,  when  in  the  in- 
terval an  operation  might  have  been  performed  with  less  than 
I  per  cent,  of  risk  in  expert  hands.  Indeed,  Richardson 
reported  500  such  cases  up  to  November,  1902,  which 
all  recovered,^  and  the  latest  statistics  of  Deaver,  Ochsner,  and 
other  expert  surgeons  are  almost  equally  good. 

This  is  certainly  a  powerful  argument  in  favor  of  having 
all  such  cases  operated  at  a  time,  and  under  circumstances; 
which  would  be  most  favorable  to  success.  While  explain- 
ing that  a  prolonged  medical  treatment  and  strict  diet  may 
cure  finally,  I  should  always  acquaint  patients  with  the  above 
remarkable  figures,  and  as  a  rule  advise  the  operation  when 
the  best  conditions  can  be  fulfilled.  In  the  following  in- 
stances, I  think,  the  operation  should  be  strongly  urged :  ( i ) 
in  all  subjects  of  the  disease  who  have  had  at  least  one  acute 
attack  and  in  whom  the  catarrhal  process  is  not  steadily  im- 
proving under  appropriate  treatment;  (2)  in  all  such  persons 
who,  by  reason  of  their  occupation,  social  position,  or  temper- 
ament, cannot  be  kept  for  months  or,  exceptionally  possibly, 
for  years  under  suitable  treatment  for  the  catarrhal  condition. 
This  treatment  must  include  a  more  or  less  stricL  diet  which 
many  patients  simply  will  not  adhere  to,  and  therefore,  in 
their  cases,  as  well  as  in  the  cases  of  those  who  have  not  the 
time  nor  money  to  devote  to  the  tedious  task  of  getting  well  by 
non-operative    means,    operation    is    clearly    the    preferable 

'  Loc.  cit. 


760  THE    GASTRO-INTESTINAL    CLINIC 

method.  In  those  patients  who  have  never  had  an  acute  at- 
tack, or  only  one  very  mild  one,  who  will  submit  to  a  long 
medical  treatment  with  a  regulated  diet,  there  is  much  less  rea- 
son for  insisting  upon  the  operation. 

Under  the  head  of  Chronic  Catarrh  of  the  Intestines,  I  have 
described  in  Lecture  LXVI.  the  dietetic,  mechanical,  and  me- 
dicinal treatment  which  is  indicated  in  chronic  appendicitis 
whenever  operative  intervention  is  declined.  Frequent  coun- 
ter-irritation over  the  diseased  appendix  should  be  especially 
insisted  on.  It  should  not  be  forgotten,  also,  that  even  when 
the  appendix  is  removed,  the  associated  catarrh  in  the  cecum, 
as  well  as  often  in  other  parts  of  the  colon,  is  not  by  any 
means  always  thereby  cured,  though  it  sometimes  is.  There 
remains  the  catarrhal  state  in  the  larger  bowel  with  its  in- 
jurious effect  on  the  general  health,  and  the  same  treatment 
which  this  then  requires,  if  skillfully  and  persistently  carried 
out  without  the  operation,  might  possibly  have  cured  the 
chronic  appendicitis  as  well. 

Report  of  Author's  Case. — A  report  of  my  o\yn  experience 
with  chronic  appendicitis  will  help  to  illustrate  the  foregoing 
account  of  the  disease.  In  the  summer  of  1900,  when  58  years 
old,  I  took  cold  by  bathing  in  a  lake  and  afterward  rowing 
in  a  wet  bathing  suit  some  distance  to  a  bathhouse.  There 
resulted  a  subacute  colitis  which  only  slowly  yielded  to  treat- 
ment and  left  behind  a  slight  constipation,  with  an  occasional 
feeling  of  discomfort  in  the  region  of  the  cecum.  After  a 
time  I  was  able  to  make  out,  by  palpation,  a  marked  sensitive- 
ness and  some  thickening  of  the  appendix.  This  condition 
was  later  confirmed  by  examinations  made  by  my  friends  Drs. 
John  B.  Deaver,  De  Forest  Willard,  AV.  J.  Hearn,  and  other 
expert  surgeons  of  Philadelphia.  I  had  been  previously  some- 
what neurasthenic  and  found  my  nerve  tone  now  distinctly 
more  lowered.  There  was  much  intestinal  flatulence  and  im- 
paired sleep  toward  morning. 

Early  the  following  summer  I  took  a  long  vacation,  and  re- 
turned much  improved  in  health,  but  still  with  a  slightly  sore 
appendix.  The  treatment  pursued  consisted  mainly  of  diet, 
systematic  exercises,  automassage  of  the  abdomen,  and  elec- 


TREATMENT    OF    APPENDICITIS  761 

tricity,  the  last  taken  very  irregularly.  A  medical  man  makes 
a  bad  patient,  especially  when  he  is  his  own  doctor.  The 
summer  of  1902  was  spent  in  part  in  the  Adirondack  woods, 
where  the  coldness  and  dampness  of  an  exceptionally  cold, 
damp  summer  aggravated  my  intestinal  trouble. 

All  autotoxccinic  nephritis  had  meanwhile  developed.  Small 
amounts  of  albumen,  with  hyaline  casts,  were  almost  constantly 
demonstrable  in  the  urine  for  the  greater  part  of  the  time,  for 
a  year  or  longer.  For  this  complication,  after  the  failure  of 
other  means,  I  took  the  static  wave  current,  as  described  in 
my  recently  published  paper  entitled  The  Influence  of  the  Sec- 
ondary Static  Currents  in  Removing  Albumin  and  Casts 
from  the  Urine.^  This  treatment,  persisted  in  faithfully 
for  several  months  continuously,  not  only  did  away  with 
all  the  renal  symptoms  with  the  help  of  diet  and  a  greater 
attention  to  physical  exercise,  but  also  seemed  to  assist 
much  in  relieving  all  the  symptoms  and  signs  referable 
to  the  appendix.  As  a  result  of  all  these  means,  my  health 
greatly  improved.  During  the  past  summer  (1903)  I  stayed 
at  home,  attended  to  a  larger  practice  than  usual,  and 
worked  hard  also  in  preparing  the  material  for  this  book.  I 
could  no  longer  feel  my  appendix,  had  no  pain  or  discomfort 
there,  and  believed  it  practically  well.  There  is  little  room  for 
doubt  that  had  I  continued  my  careful  hygienic  way  of  liv- 
ing, I  should  have  had  no  more  trouble  from  it,  and  that  a 
lessening  of  confining  work,  with  a  persistence  in  treatment, 
would  have  effected  a  cure. 

But,  unfortunately  for  me,  matters  finally  assumed  such  a 
shape  that  work  on  the  book  had  to  be  pushed  at  a  rate  that 
left  me  no  time  for  rest  or  exercise  out  of  doors,  and  much 
overtaxed  my  energies.  After  several  months  of  such  un- 
hygienic living,  some  grumblings  began  to  recur  in  the  cecal 
region,  and  finally  I  could  again  feel,  at  times,  a  slightly  thick- 
ened and  sensitive  appendix.  There  was  again  a  very  abnor- 
mal amount  of  intestinal  flatus,  and  much  impairment  of 
sleep. 

A  very  slight  attack  of  subacute  catarrhal  appendicitis  then 
developed  under  peculiar  circumstances. 

November  29  some  dull  pain  and  tenderness  on  pressure,  or 
on  bending  the  body,  were  experienced  in  the  right  loin  and 
side.     At  the  same  time    a  little  twinge  was  occasionally  felt 

'  Am.  Med.,  November  28,  1903. 


762  THE    GASTRO-INTESTINAL    CLINIC 

in  the  region  of  the  appendix,  but  the  pain  and  discomfort 
were  predominantly  in  the  back  and  right  side,  just  below  the 
site  of  the  kidney.  Muscular  rheumatism  was  at  first  sus- 
pected, and  later  the  possibility  of  a  large  stone  in  the  pelvis 
of  the  kidney  trying  to  enter  the  ureter.  On  the  morning  of 
the  30th  the  discomfort  in  the  whole  right  side  and  loin  was 
marked,  but  the  temperature  reached  only  99.8  at  the  highest, 
which  was  on  the  .  evening  of  that  day,  and  there  was  no 
nausea,  while  the  intestinal  flatulence  from  which  I  had  been 
suffering  was  almost  entirely  absent  during  the  two  days.  In 
consequence,  I  enjoyed  a  greater  feeling  of  well-being  than 
before,  and  continued  with  my  practice  and  writing  as  usual. 
On  the  morning  of  December  i  Dr.  John  B.  Deaver  examined 
me  and  found  a  subacute  appendicitis — nothing  else  demon- 
strable— whereupon  I  decided  to  have  the  pperation  of  ap- 
pendectomy done  at  once,  as  the  shorter  and  surer  way  to  a 
complete  cure,  and  the  only  way  for  one  unable  or  unwilling 
to  give  up  hard  work  and  carry  out  strictly  the  necessary  line 
of  medical  treatment. 

My  improved  feeling  of  well-being,  in  spite  of  a  con- 
gested appendix,  was  probably  because  its  outlet  had  swol- 
len shut  and  there  was  no  more  leakage  of  septic  matter 
from  it. 

The  operation  was  done  December  2,  at  the  Samaritan  Hos- 
pital, by  Dr.  Deaver,  assisted  by  Dr.  W.  Wayne  Babcock,  sur- 
geon to  the  hospital,  and  the  resident  staff  of  that  institution. 
The  appendix  was  found  swollen  to  nearly  double  the  normal 
thickness,  considerably  infiltrated,  and  the  vessels  much  in- 
jected. The  mucosa  presented  the  usual  signs  of  catarrhal 
inflammation,  and  there  was  a  slight  narrowing  of  the  lumen 
at  the  cecal  end. 

My  convalescence  was  uneventful.  On  the  fifth  day  the 
stitches  were  removed  by  Dr.  Babcock,  and  on  the  beginning 
of  the  eleventh  day  I  was  able  to  leave  the  hospital. 

A  thorough  examination  of  my  urine,  made  shortly  after  the 
operation,  revealed  no  trace  of  either  albumin  or  casts. 

Further  Considerations  Regarding  the  Management  of  Ap- 
pendicitis.— In  few  fields  have  the  triumphs  of  surgery  been 
more  notable  than  in  that  of  the  appendix.  The  general  belief 
is  that,  unlike  the  ovary  or  kidney,  it  is  not  only  either  a  vital 
or  very  useful  organ,  but  a  positively  dangerous  one,  or  at  least 


TREATMENT  OF  APPENDICITIS  763 

one  likely  to  become  a  source  of  danger  at  any  time.  The  ap- 
pendix has  hitherto,  at  all  events,  been  considered  practically 
useless.  A  recent  English  writer,  however,  maintains  that  it 
normally  performs  an  important  function  and  that  its  loss  by 
operation  or  otherwise  causes  some  impairment  of  the  health. 

But  for  the  considerable  inconvenience  and  at  least  slight 
risk  of  the  operation,  many  persons  would  have  it  removed 
while  well.  When  the  organ  becomes  diseased  in  whatsoever 
degree  or  form,  the  reasons  for  wishing  to  be  rid  of  it  alto- 
gether  are  greatly  increased. 

Supposing  a  patient  attacked  with  acute  appendicitis  to  be  so 
situated  or  so  constituted  temperamentally  that  he  would  prefer 
the  operation  of  appendectomy,  done  under  the  best  possible 
conditions,  to  the  risks  of  future  acute  attacks,  or  the  tedious- 
ness  and  expense  of  a  prolonged  medical  campaign  against  the 
chronic  disease  which  usually  follows,  the  practical  cjuestion 
arises.  How  can  he  most  safely  effect  his  purpose?  If  the  at- 
tack has  come  while  he  is  in  any  of  the  larger  cities,  he  will 
be  reasonably  sure  of  a  prompt  diagnosis,  and  could  have  an 
early  operation  done  with  such  skill  and  care  as  to  involve  not 
very  much  more  risk  than  attends  what  is  called  the  interval 
operation,  for  which  the  time,  place,  and  surgeon  can  all  be 
carefully  chosen  beforehand. 

Unfavorable  Conditions  for  Operation. — But  suppose,  in- 
stead, he  is  on  a  sea  voyage,  a  gunning  trip,  or  camping  in 
the  woods  hundreds  of  miles  from  any  town,  when  the  acute 
attack  comes?  Or  for  that  matter,  suppose  it  finds  him  in 
some  remote  country  village,  where  the  only  medical  man  ob- 
tainable may  have  never  even  seen  a  laparotomy.  Then  the 
only  alternative  would  be  to  call  the  nearest  abdominal  sur- 
geon, who  would  most  frequently  arrive  late,  and  have  to  do 
the  always  dangerous  late  operation  with  probably  much  less 
skill  than  that  of  a  Deaver  or  Richardson,  and  might  possibly 
be  a  bungler  with  a  very  faulty  technique,  and*unable  to  afford 
him  as  much  hope  of  recovery  as  he  would  have  Under  the 
most  ordinary  medical  treatment. 


764  THE    GASTRO-INTESTINAL    CLINIC 

On  the  other  hand,  it  is  claimed  that  under  the  rest  and 
starvation  treatment  of  acute  appendicitis  vigorously  adhered 
to  from  the  beginning,  even  the  gravest  cases  may  usually  be 
carried  through  to  an  interval  when  an  operation,  which  would 
be  practically  devoid  of  risk,  could  be  done  by  almost  any 
fairly  competent  surgeon,  though  there  would  then  be  op- 
portunity for  the  selection  of  a  convenient  time,  a  suitable 
place,  and  an  expert  laparotomist,  if  desired. 

Under  these  circumstances  it  seems  to  me  the  very  height 
of  unwisdom  to  teach  general  practitioners  and  the  laity  that 
an  operation  is  the  only  remedy  in  acute  appendicitis.  Such  a 
doctrine,  if  fully  accepted,  means  that  any  half -trained  sur- 
geon, no  matter  how  clumsy,  inexperienced,  or  dirty,  should  be 
permitted  in  an  emergency  to  open  the  belly  of  an  appendi- 
citis patient. 

Even  if  Ochsner  and  his  starvation-anticathartic  method, 
with  its  extraordinary  small  death  rate,  had  never  been 
heard  of,  it  would  still  be  safer  not  to  operate,  except  under 
reasonably  favorable  conditions,  since  the  old  Alonzo  Clark 
method  of  treating  attacks  of  so-called  local  peritonitis,  which 
were  really  in  most  cases  appendicitis,  saved  a  very  large 
majority  of  cases — doubtless,  too,  because  it  prevented  peri- 
stalsis and  the  spread  of  the  infection.^ 

Then,  let  me  again  urge  upon  you  that  you  adopt  the  safe 
rule  of  withholding  food  and  cathartics  in  all  doubtful  attacks 
beginning  with  fever  and  pain  in  the  abdomen  anywhere,  until 
you  can  exclude  the  possibility  of  appendicitis.  When  the 
suspicion  of  this  affection  is  strong,  and  especially  if  there  be 
nausea,   or  any  symptom  of  a  laboring  stomach,   wash  the 

1  Fiertz  in  the  Correspondettz-Blatt  f.  Schweizer  Aerzte  oi  March  10, 
1910,  abstracted  in  the  y^.  A.  M.  A.,  of  April  23,  1910,  p.  1416,  reports  hav- 
ing cured  promptly  51  cases  of  acute  appendicitis  by  a  novel  treatment  in 
spite  of  the  fact  that  in  12  of  them  perforation  occurred  The  patients 
were  kept  still  in  bed  and  given  two  or  three  times  a  day  a  rectal  injec- 
tion of  a  glass  of  a  I  in  1000  solution  of  salicylic  acid  mixed  with  a  glass  of 
oil,  the  receptacle  held  as  high  as  possible  ;  then  a  quart  of  the  salicylic 
solution  allowed  to  flow  in  slowly,  the  patient  meanwhile  kept  perfectly 
motionless.  Presumably .  the  patients  were  not  given  either  food  or 
cathartics. 


TREATMENT  OF  APPENDICITIS  765 

latter  out,  so  as  to  begin  the  fight  without  any  handicap  upon 
the  patient. 

If,  then,  the  disease  proves  to  be  something  else,  no  harm 
will  have  been  done,  but,  on  the  contrary,  good.  Virtually,  all 
the  forms  of  disease  with  which  appendicitis  is  likely  to  be 
confounded  will  be  the  better  for  such  a  conservative  begin- 
ning of  the  treatment. 

After  this  good  start,  if  you  find  a  severe  type  of  appendi- 
citis to  be  developing,  call  a  consultation,  including  always  as 
one  consultant  the  best  obtainable  abdominal  surgeon,  and 
whatever  may  be  subsequently  done,  you  will  have  nothing  to 
regret. 

One  reason  urged  in  some  quarters  for  avoiding  a  laparot- 
omy in  the  milder  attacks  of  appendicitis,  especially  in  the 
catarrhal  form  when  the  symptoms  are  not  threatening,  is  the 
fact  that  adhesions  so  frequently  result  from  operative  inter- 
vention and  give  rise  then  to  annoying,  as  well  as,  sometimes, 
dangerous  complications  afterward.  Ford  of  Utica,  N.  Y., 
long  ago  advised  that  in  catarrhal  appendicitis,  whether  treated 
by  operation  or  without,  the  bowels  after  the  attack  be  kept 
well  filled  with  some  kind  of  pulpy  food  and  regularly  opened 
by  salines — that  is,  kept  active  instead  of  at  rest — in  order  to 
prevent  the  adhesions  which  rest  and  opiates  tend  to  favor. 
When  adhesions  have  already  formed,  he  recommended  deep 
massage  and  large  doses  of  galvanism  locally  as  a  means  of 
stretching  or  dissolving  them. 

Ford's  method  of  after  treatment,  while  probably  safe  in 
the  milder  cases  for  which  he  advised  it,  should  not  be  risked 
until  all  danger  of  peritonitis  or  abscess  has  passed. 

However,  in  summing  up  all  the  evidence  for  and  against 
early  operative  treatment  in  appendicitis,  there  is  a  decided 
preponderance  in  favor  of  operating  during  the  first  thirty-six, 
and,  possibly,  the  first  forty-eight,  hours  in  all  cases,  before 
perforation  of  the  appendix  or  rupture  of  an  abscess  has  oc- 
curred— in  all  cases  at  least  which  are  not  certainly  catarrhal 
merely — provided  a  competent  surgeon  caii  be  obtained. 


LECTURE  LXIX 
CONSTIPATION 

Constipation  may  best  be  defined  as  an  imperfect  empty- 
ing of  tlie  bowels.  It  is  a  morbid  condition  which  may  result 
from  many  different  diseases.  Though  only  a  symptom  of 
some  pathologic  state,  either  in  the  innervation  or  muscular 
apparatus  of  the  intestines,  or  of  disease  elsewhere  in  the  body, 
it  is  exceedingly  prevalent  in  civilized  communities,  and  in  its 
chronic  form  is  almost  never  cured  by  the  administration  of 
medicines  alone,  nor  by  any  directly  opening  measures, 
whether  in  the  form  of  laxative  drugs,  per  os  or  per  rectum,  or 
by  colon  douches,  or  even  the  usual  routine  massage. 

Etiology. — To  enumerate  all  the  diseases  which  seem  often 
to  stand  in  a  causal  relation  to  constipation  w^ould  almost  ex- 
haust the  list  of  important  known  maladies.  Prominent  among 
those  which  nearly  always  produce  constipation  (and  many  of 
them  complete  obstruction)  are  meningitis,  brain  tumors, 
among  other  cerebral  and  spinal  affections,  lead  poisoning, 
volvulus,  invagination  of  the  intestines,  hernia,  peritonitis,  ap- 
pendicitis, abdominal  and  pelvic  tumors,  etc.  Tumors,  however, 
sometimes  cause  diarrhea.  Constipation  may  also  be  a  result  of 
blood  impoverishment,  and  of  most  depressing  diseases  of  the 
nervous  system,  inflammation  of  the  stomach  or  upper  intestines, 
ulcer  or  tumor  of  the  same,  and  stricture  of  the  bowel ;  also,  of 
abnormalities  in  the  gastric  secretion,  especially  hyperchlorhyd- 
ria,  many  diseases  of  the  liver  and  pancreas,  hemorrhoids  or 
fissure  of  the  anus,  and  particularly  ptoses  of  the  viscera, 
backward  displacement  of  the  uterus  and  other  diseases  of 
the  pelvic  organs.  Prolapse  of  the  right  kidney  (movable 
kidney),  which  is  exceedingly  common  in  women,  is  often  a 

766 


CONSTIPATION  767 

factor  in  the  production  of  constipation  by  obstructing  at 
times  the  lumen  of  the  duodenum,  and  the  agglutination  of 
folds  of  intestine  to  each  other  or  to  neighboring  structures 
may  seriously  impede  the  onward  propulsion  of  the  feces. 
(See  Lecture  LXIV.) 

The  most  prolific  causes  of  chronic  habitual  constipation, 
and  those  most  amenable  to  non-operative  treatment,  are  to 
be  found  in  either  one  of  two  opposite  conditions  involving 
both  the  nervous  and  the  muscular  apparatus  of  the  gastro-m- 
testinal  tract,  and  recjuiring  cjuite  different  methods  of  treat- 
ment. These  are  atony  and  spasm.  Atony  of  the  stomach 
walls,  whether  amounting  to  dilatation  or  only  to  motor  in- 
sufficiency with  delayed  emptying,  results  generally  in  a  de- 
ranged intestinal  peristalsis  showing  itself  usually,  at  first,  in 
the  form  of  constipation.  Atony  in  any  part  of  the  intestine 
must  manifestly  produce  a  like  result. 

A  spastic  state  of  the  pylorus  or  of  the  muscles  of  the  in- 
testines, leading  to  irregular  local  tonic  contractions  of  the 
circular  fibers,  is  a  common  and  often  unrecognized  cause  of 
constipation.  In  hysteria,  and  in  certain  forms  of  neuras- 
thenia, such  localized  spasms  are  perhaps  almost  as  frecjuently 
responsible  for  difficult  defecation  as  muscular  atony,  and  much 
more  frequently  than  any  other  single  cause.  It  is  probable, 
also,  that  the  deranged  digestion,  both  gastric  and  intestinal, 
which  so  often  accompanies  neurasthenia,  by  producing  fer- 
mentation and  abnormally  acid  conditions  in  the  alimentary 
canal,  conduces  powerfully  to  the  spasmodic  action;  and  it  is 
likely  that  portions  of  the  bowel,  the  mucous  membrane  of 
which  is  in  a  state  of  chronic  catarrhal  inflammation,  have  an 
increased  tendency  to  spastic  contractions. 

Authorities  differ  widely  as  to  the  relative  importance  of 
various  factors  in  the  causation  of  both  atonic  and  spastic 
constipation.  Glenard  considered  displacements  of  the  stom- 
ach and  intestines  as  chiefly  responsible,  while  Emminghaus 
traces  habitual  constipation  to  degenerative  changes  in  the 
splanchnics,  and  Dunin  thinks  it  attributable  mainly  to  central 


^68  THE    GASTRO-IXTESTIXAL    CLIXIC 

functional  anomalies  in  the  nervous  system.  Boas^  finds  it 
difficult  either  to  deny  or  confirm  these  theories ;  but  points  out 
that  in  any  fully  developed  case  of  neurasthenia  with  consti- 
pation there  may  be  found  a  vicious  circle,  and  he  thus  aptly 
illustrates  his  idea  by  describing  a  supposed  case  such  as  we  all 
often  see : 

"  A  previously  healthy  woman  begins  to  suffer  with  consti- 
pation and  requires  aperients.  Gradually  these  become  in- 
efficient; defecation  is  more  and  more  difficult  and  imperfect. 
At  the  same  time,  there  is  taken  a  decreased  amount  of  nour- 
ishment, either  in  consequence  of  a  misuse  of  purgatives,  or  as 
a  therapeutic  measure  ('easily  digestible  food'),  or  as  a  re- 
sult of  a  bad  general  condition,  or  from  anaemia  or  gastric 
derangements,  c.  g.,  atony.  Naturally,  then,  follow  emacia- 
tion, dropping  of  the  abdominal  viscera,  and,  with  these,  in- 
crease of  the  constipation,  and  finally,  as  a  capstone  to  all  these 
symptoms,  the  picture  of  well-marked  neurasthenia.  Here,  as 
every  experienced  physician  must  concede,  the  enteroptosis  is 
not  the  cause,  but  the  consequence,  of  the  habitual  constipa- 
tion, and  the  same  holds  good  also  for  the  neurasthenia.  But, 
on  the  other  hand,  the  loss  of  flesh  from  whatever  cause  can 
lead  to  the  development  of  visceral  displacements,  and  so  pro- 
duce constipation,  or,  perhaps  more  correctly,  favor  its  develop- 
ment, as  also,  in  like  manner,  genuine  neurasthenia  (according 
to  Dunin's  view)  may  prove  the  basis  for  the  development 
often  of  even  very  stubborn  forms  of  constipation." 

An  insufficient  amount  of  food  or  drink,  or  long-continued 
overeating,  a  too  bland  diet  lacking  in  refuse  matters,  or  a  too 
predominantly  nitrogenous  diet,  sedentary  occupations,  defi- 
cient exercise,  and  a  want  of  regularity  in  going  to  stool  are 
further  important  causes  of  chronic  atonic  constipation. 

Symptomatology. — It  has  been  denied  that  auto-intoxica- 
tion can  be  caused  by  dry  feces,  no  matter  how  long  retained, 
and  in  Gennany  the  resulting  phenomena  are  more  generally 
considered  to  be  reflex ;  but,  however  accounted  for,  some  of 
'  "  Diagnostik  u.  Therapie  der  Darmkrankheiten,"  Leipzig,  1899. 


CONSTIPATION  769 

the  following  symptoms  may  be  constantly  observed  as  a  result 
of  constipation :  Dizziness,  headache,  insomnia,  mental  hebe- 
.  tude  or  depression.  Other  frec^uent  symptoms,  which  usually 
disappear  more  or  less  cjuickly  after  overcoming  the  constipa- 
tion, are  nausea,  furred  tongue,  offensive  breath,  excessive 
flatulency,  colics,  failing  appetite,  as  well  as  other  indications 
of  impaired  digestion,  urticaria,  and  various  other  affections 
of  the  skin,  and  objectively  ascertained,  often  deranged  gastric 
secretion  (especially  excessive  HCl)  and  probably  lowered 
gastric  motility,  as  well  as  indicanuria  and  excess  of  the  aro- 
matic sulphates,  and  of  the  total  acids  in  the  urine.  Other  ob- 
jective signs  are  dry,  hard  stools,  lumpy  or  made  up  of 
agglutinated  balls  of  different  color  and  consistency,  or  hard 
globular  feces  of  various  sizes,  from  that  of  hazelnuts  up,  or 
in  spastic  cases,  as  well  as  in  cases  of  organic  stricture,  un- 
usually small  cylinders  like  lead-pencils. 

Periodic  transient  attacks  of  diarrhea,  with  usually  mingled 
lumps  and  hquid  feces,  which  are  often  exceedingly  offensive, 
may  be  considered  as  a  symptom  of  chronic  constipation.  In 
these  cases  there  is  irritation  of  both  the  mucous  membrane 
and  musculature  of  the  intestines  by  the  long-continued  press- 
ure of  the  hard  fecal  masses  and  distention  from  the  im- 
prisoned gases,  and  probably  a  catarrhal  process  is  also  set  up 
in  places,  through  infection  from  the  enormously  multiplied 
bacteria  in  the  stagnant  feces,  with  abundant  formation  of  or- 
ganic acids  from  fermentation. 

It  is  a  serious  mistake  to  treat  such  diarrheal  attacks  by 
opiates  and  astringents,  or  even  by  antiseptics  alone,  when 
nature  has  so  clearly  pointed  the  way  to  a  prompt  clearing  out 
of  the  intestines.  Recurrent  diarrheas,  with  either  nc  stools 
or  insufficient  stools  between,  are  signs  of  chronic  atonic  con- 
stipation, or  else  of  a  mild  chronic  enteritis,  and  need  to  be 
treated  accordingly. 

The  Differential  Diagnosis  between  Atonic  and  Spastic 
Constipation. — It  will  be  of  chief  practical  importance  to  dif- 
ferentiate the  atonic  and  spastic  forms  of  constipation  from 


770  THE   GASTRO-INTESTINAL    CLINIC 

each  other,  and  both  of  these  from  the  organic  changes  which 
may  impede  defecation.  Westphalen  ^  of  St.  Petersburg  has 
written  elaborate  papers  concerning  both  the  atonic  and  spastic 
forms  of  constipation,  and  has  pointed  out  the  differences  be- 
tween the  two  very  clearly.  Numerous  authors,  including 
Nothnagel,  Boas,  Flick,  Fleiner,  and  others,  in  Germany  es- 
pecially, have  mentioned  the  spastic  as  a  possible  form  of  con- 
stipation, but  with  a  few  exceptions  do  not  lay  much  stress 
upon  it.  3vlany  cases  of  this  affection,  which  were  seen  in  my 
own  earlier  practice,  were  not  recognized  as  such.  They  were 
often  given  abdominal  massage,  not  only  without  benefit,  but 
with  the  result  of  increasing  the  constipation.  These  were 
patients  suffering  from  neurasthenia  in  connection  with  gastro- 
intestinal derangements,  and  many  of  them  showed  spastically 
contracted  abdominal  muscles  and  excessive  knee  jerks.  I  do 
not  now  prescribe  the  usual  vigorous  abdominal  massage  for 
such  patients,  though  I  sometimes  find  them  to  be  benefited  by 
light  stroking — effleurage;  but  try  to  cure  them  by  general 
roborant  measures,  trusting  to  diet,  special  exercises,  oil  en- 
emas, etc.,  to  keep  their  bowels  open.  Besides  the  fact  that 
spastic  constipation  occurs  in  nervous,  excitable  patients  with 
heightened  reflexes,  Westphalen  points  out  that  in  such  cases 
the  stools,  though  usually  complete,  are  passed  with  the 
greatest  difficulty,  and  often  only  after  much  straining  and  long 
delay.  Afterward  there  is  left  behind  an  unsatisfactory  feel- 
ing, as  though  the  rectum  had  not  been  perfectly  emptied, 
e^■en  when  an  examination  would  show  that  no  feces  remained 
there.  This  sensation  he  considers  to  be  due  to  an  irritated 
condition  of  the  nerve-endings  in  the  rectum.  A  like  hyper- 
sesthesia  of  the  mucous  membrane  of  the  bowel  is  supposed  to 
play  a  part  in  producing  the  irregular  contractions  of  the  cir- 
cular muscles  which  hinder  the  onward  progress  of  the  feces. 
A  contrary  group  of  symptoms  obtains  in  uncomplicated  atonic 
constipation.     Here  the  amount  of  feces  passed  daily  is  too 

'  Archiv  f.   Verdauungskrankhezteft,  vol.  vi.,  No.  2,  and  vol.  vii.,  Nos. 
I  and  2. 


CONSTIPATION  7/1 

small,  not  at  all  in  proportion  to  the  quantity  of  food  taken, 
and  yet  the  patient  may  pass  them  with  little  straining  or 
effort  and  feel  afterward  as  though  he  had  had  a  thorough 
evacuation.  He  may  also  be  neurasthenic,  but  will  not  likely 
have  such  exaggerated  reflexes.  His  abdominal  muscles  will 
not  be  so  rigid  upon  palpation,  and  a  finger  introduced  into  the 
rectum  will  not  be  so  tightly  grasped. 

The  Stools  in  Atonic  and  Spastic  Constipation. — With  re- 
gard to  the  appearance  of  the  stools  in  the  two  forms,  all 
agree  that  slender  ones  of  lead-pencil  or  little-finger  size, 
whether  long  or  short,  mean  a  spastic  contraction  of  some  por- 
tion of  the  bowel,  when  an  organic  stricture  can  be  excluded, 
except  in  cases  of  semi-starvation,  especially  in  cancer,  as  a 
result  of  which  the  lumen  of  the  intestine  may  become  greatly 
lessened.  These  slender  stools  may  be  canaliculated.  I  may 
add,  as  an  important  diagnostic  point  observed  by  myself,  that 
spastic  conditions  are  almost  never  constant,  but  the  patients 
will  at  some  time,  under  favorable  conditions,  however  in- 
duced (often  as  a  i-esult  of  nerve  sedatives),  pass  stools  of 
normal  caliber,  whereas,  when  there  is  a  permanent  stricture, 
the  stools  are  always  in  either  a  slender  form  or  fluid.  West- 
phalen  also  lays  some  stress  upon  the  consistency  of  the 
stools,  insisting  that,  while  they  are  very  hard  and  dry,  and 
often  covered  with  a  thin  layer  of  mucus  in  the  atonic  form, 
those  passed  in  the  spastic  form  contain  no  mucus  outside  or 
inside,  but  have  usually  a  larger  percentage  of  water,  and  are 
tougher,  more  sticky,  and  of  a  more  glistening  appearance — 
gUinzend.  The  latter*  also  contain  less  gas,  so  that  they  will 
not  float  in  water,  as  normal  feces  or  those  from  a  case  of 
atonic  constipation  usually  will.    ^ 

Careful  palpation  and  percussion  over  the  abdomen  will 
show  differences  between  the  atonic  and  spastic  types  of  con- 
stipation. In  the  former,  a  more  general  tympany  should  be 
demonstrable,  with  possibly  masses  of  hard  feces  to  be  felt  in 
tlie  cecum  or  flexures  of  the  colon ;  while,  in  the  latter  type,  one 
,  may  often  feel  portions  of  the  intestine  contracted  like  a  cord 


772  THE    GASTRO-INTESTINAL    CLINIC 

under  the  finger.  Then,  in  the  spastic  form,  too,  there  are 
more  frequently  very  sensitive  spots  in  various  part  of  the  abdo- 
men, especially  in  the  region  of  the  umbilicus,  and  there  are 
portions  over  which  marked  tympany  contrasts  sharply  with  the 
duller  note  of  adjoining  regions,  showing  imprisoned  gas.  Ta- 
betic patients  in  an  early  stage  are  likely  to  present  the  phenom- 
ena of  spastic  constipation.  Judging  from  my  observation,  it  is 
highly  probable  that  most  neurasthenic  patients  who  suffer 
excessively  from  intestinal  flatulence  which  accumulates  in 
places  to  their  great  discomfort,  finally  passing  with  bor- 
borygmi  through  evidently  narrowed  coils  of  intestine,  while 
the  feces  themselves  are  retained,  have  the  spastic  form  of  con- 
stipation, however  complicated  with  other  conditions.  Finally, 
you  may  find  both  forms  in  the  same  case,  since  it  is  quite 
possible  for  atonic  constipation  to  be  complicated  at  times  by 
a  spastic  condition. 

Constipation,  from  Strictures  or  Other  Organic  Obstructions. 
— From  the  constipation  or  obstruction  dependent  upon  serious 
organic  disease,  such  as  strictures,  tumors,  inflammatory  af- 
fections, etc.,  both  the  atonic  and  spastic  form  of  impeded  de- 
fecation can  generally  be  differentiated  by  thorough  and  pains- 
taking examinations,  with  the  help  of  our  modern  exact 
methods.  Other  serious  conditions  which  must  be  differen- 
tiated from  the  simpler  forms  of  constipation  are  adhesions  of 
intestinal  loops  to  each  other  or  to  adjacent  structures  follow- 
ing operations  or  peritonitis,  partial  twists  of  the  bowel  (vol- 
vulus), and  chronic  forms  of  intussusception.  Some  of  these 
it  is  impossijjle  at  times  to  diagnosticate,  except  by  exclusion, 
liut  intussusception  in  a  chronic  form  should  be  suspected 
whenever  there  are  recurrent  colics  accompanied  by  the  pas- 
sage of  a  little  blood  or  mucus  or  both. 

The  above-mentioned  hint  as  to  the  constant  smallness  of 
the  stools  in  organic  stricture  should  be  helpful  in  making  a  di- 
agnosis. Filling  the  stomach  with  gas,  and  again  with  liquid, 
and  afterward,  if  necessary,  treating  the  colon  in  the  same 
way,  will  often  reveal  latent  tumors  and  their  attachment,  and 


CONSTIPATION  773 

a  thorough  douching  of  the  colon  with  warm  water  will 
usually  demonstrate  a  chronic  enteritis  by  the  amount  of 
mucus  brought  away.  You  should  be  careful  not  to  mistake 
for  morbid  growths  the  masses  of  hardened  feces  which  can 
often  be  felt  in  chronic  constipation,  especially  in  the  cecum, 
flexures  of  the  colon,  sigmoid,  and  rectum.  Indeed,  before 
making  a  final  diagnosis  in  any  case  of  suspected  abdominal 
tumors,  the  bowels  should  be  thoroughly  emptied  by  repeated 
enemas  of  oil,  followed,  if  necessary,  by  flushing  the  colon 
with  a  warm  saline  solution  after  the  administration  of  a  full 
dose  of  belladonna  or  atropine  to  relax  any  spasmodic  con- 
tractions. 

Areas  of  dullness  over  parts  of  the  colon  are  generally  due 
to  a  spastic  contraction  of  such  parts,  since  in  atonic  con- 
stipation, even  when  the  bowel  is  loaded  with  retained  feces, 
the  percussion  note  is  usually  tympanitic. 

Constipation  can  not  only  result  from  many  different  causes, 
but  its  possible  evil  consequences  are  quite  as  numerous  and 
varied.  A  very  large  proportion  of  the  chronic  diseases 
which  afflict  mankind  and  greatly  shorten  life,  as  well  as  some 
very  serious  acute  forms  of  disease,  result,  in  the  main,  directly 
or  indirectly  from  prolonged  constipation,  and  the  dietetic 
faults  upon  which  it  chiefly  depends.  Such  diseases  include 
nearly  all  the  affections  of  the  gastro-intestinal  tract  not  due 
to  entozoa  or  poisons  from  without  the  body,  except  cancer 
(and  possibly  that  also,  since  excessive  meat-eaters,  who  are 
generally  constipated,  are  believed  by  some  careful  observers 
to  be  particularly  prone  to  malignant  disease)  ;  many  skin  dis- 
eases, arteriosclerosis  with  its  involvement  of  the  heart, 
arteries  and  kidneys  directly,  as  well  as  indirectly  the  brain 
and  nervous  system  generally;  and  so  On  through  an  almost 
endless  list,  including  acute  intestinal  obstruction,  apoplexy, 
etc. 

Do  not  let  patients  continue  indefinitely  with  laxatives.  Our 
duty  is  to  ascertain  the  exact  cause  of  the  constipation,  and 
then  to  cure  it,  as  is  possible  in  a  large  majority  of  cases. 


LECTURE  LXX 

CONSTIPATION,   CONTINUED— PROGNOSIS 
AND   TREATMENT 

Constipation  is  curable  when  its  cause  can  be  cured  or  re- 
moved. If  the  cause  be  some  functional  nervous  affection,  a 
displacement  of  the  stomach  or  liver,  chronic  catarrh  of  the 
stomach  or  small  intestine,  excessively  acid  or  deficient  gastric 
juice,  gastric  or  intestinal  atony,  or  spastic  contractions  of 
the  pylorus  or  of  parts  of  the  intestines,  the  condition  is  gen- 
erally remediable  by  some  one  or  more  of  the  hygienic,  hydri- 
atic,  mechanical,  and  medical  measures  which  we  have  at  com- 
mand. Even  gastric  ulcer,  movable  kidneys,  and  displacements 
or  kinks  of  the  intestines,  you  may  often  be  able  to  overcome 
by  a  combination  of  several  of  these  non-surgical  measures, 
and  thus  cure  the  resulting  constipation. 

Serious  cases  of  obstruction,  whether  due  to  any  of  the 
above-mentioned  causes  or  to  hernia,  volvulus,  adhesions  from 
former  attacks  of  appendicitis,  or  from  local  peritonitis  else- 
where, usually  respond  to  surgical  intervention  when  invoked 
sufficiently  early,  now  that  abdominal  surgery  has  become  so 
Avonderfully  developed  and  perfected.  When  a  tumor  inter- 
feres with  defecation,  the  prognosis  depends  upon  its  charac- 
ter, location,  and  size,  and  the  ability  of  the  patient  to  bear 
the  necessary  operation.  The  chronic  organic  diseases  of 
the  nerve  centres  being  generally  incurable,  the  prognosis  of 
the  constipation  dependent  upon  them  is  necessarily  bad.  Most 
pelvic  causes  of  constipation  can  be  remedied  in  some  way 
nowadays,  except  malignant  growths,  and  even  these  will 
sometimes  yield  to  prompt  surgery  or  the  Massey  method — 
see  page  928. 

774 


CONSTIPATION  775 

Treatment. — Chronic  habitual  constipation,  resulting  from 
any  of  the  above-mentioned  diseases,  can  only  be  overcome,  of 
course,  by  a  successful  treatment  of  such  diseases.  Many  of 
these  have  already  been  discussed  in  previous  lectures,  and 
others  will  be  later. 

It  remains  to  consider  especially  the  two  principal  types  of 
constipation,  the  atonic  and  the  spastic.  These  are  not  only  the 
types  most  frequently  encountered,  but,  though  generally  sec- 
ondary to  other  affections,  they  both  depend  much  more  than 
other  forms  of  constipation  upon  a  diseased  condition  in  the 
nerve  supply  or  muscular  apparatus  of  the  intestines  them- 
selves. This  is  particularly  true  of  the  atonic  form.  Impaired 
gastric  motility  or  a  faulty  secretion  on  the  part  of  the  liver, 
peptic  or  pancreatic  glands,  or  a  weak,  depressed  nervous  sys- 
tem, as  well  as  numerous  other  maladies,  often  conduces 
greatly  to  this  type  of  constipation,  and  there  is  perhaps  always 
some  such  predisposing  factor  in  the  causation.  Yet  a  sed- 
entary life,  with  lack  of  exercise  leading  to  lowered  vigor  of 
the  intestinal  muscles,  abuse 'of  purgatives  (one  of  the  crying 
evils  of  the  times  for  which  we  doctors  are,  I  fear,  in  large 
part  responsible),  and  also  a  too  concentrated  diet,  are  all 
causes  which  may  set  up  atonic  constipation  by  a  direct  action 
upon  the  intestines  themselves. 

To  cure  this  condition,  you  will  need,  therefore,  to  impress 
upon  your  patients,  first  of  all,  that  even  the  mildest  laxative 
drugs  must  be  abandoned,  or  taken  only  in  the  smallest  possi- 
ble effective  doses  when,  and  so  long  as,  they  are  indispensable, 
which  they  rarely  are;  that  exercise,  especially  of  the  trunk 
muscles,  must  be  practiced  every  day  to  the  end  that  both 
tliese  and  the  muscles  involved  in  the  peristalsis  may  be  grad- 
ually strengthened  up  to  the  normal — a  process  which  may 
require  many  months  to  accomplish — and  you  must  strenu- 
ously insist  also  upon  such  a  modification  of  the  diet  as  shall 
afford  refuse  matter  enough  in  bulk  to  effect  the  necessary 
distention  and  stimulation  of  the  intestines. 

Of  course  you  will  see  numerous  patients  in  whom  all  this 


7/6  THE    GASTRO-IXTESTIXAL    CLINIC 

cannot  be  easily  done.  There  are  many  cases  of  constipation 
complicated  with,  or  dependent  upon,  catarrh  of  the  stomach 
or'  small  intestine,  and  the  process  may  also  involve  a  part  or 
all  of  the  colon.  In  these,  before  you  can  cure  the  con- 
stipation, you  must  first  get  rid  of  the  catarrhal  process  by 
the  help  of  an  unirritating  and  often  somewhat  constipating 
diet,  meanwhile  securing  sufficient  bowel  evacuations  by  the 
least  disturbing  methods  that  will  effect  the  object.  This  will 
rarely  be  pills  or  any  of  the  resinous  laxatives  in  any  form. 
Olive  oil  by  the  mouth,  with  plenty  of  drinking  water,  will 
sometimes  suffice.  Enemas  of  olive  oil  or  cotton-seed  oil,  or, 
in  some  cases,  of  a  tepid  or  cold  saline  solution,  will  usually 
prove  less  irritating  than  any  aperients  by  the  mouth,  and  the 
former  will  seldom  fail  when  skillfully  used.  In  all  cases, 
when  not  otherwise  contra-indicated,  the  special  exercises  for 
the  abdominal  muscles  described  in  Lecture  XXIII.  should  be 
practiced  daily  in  a  well-ventilated  room.  Massage  of  the  ab- 
domen will  assist  in  curing  the  catarrhal  process  as  well  as  in 
directly  overcoming  the  constipation,  except  when  there  is  a 
spastic  complication.  The  constant  electric  current  (galvan- 
ism) applied  to  the  abdomen  and  lower  spine,  or  the  inter- 
rupted current  (faradism),  static-wave,  static-induced,  or  sinu- 
soidal current,  or  vibratory  stimulation  within  the  rectum  will 
often  proA"e  curative.  In  the  catarrhal  conditions,  whether  they 
are  primarily  causative  or  only  complications,  actual  curative 
results  may  often  be  obtained  from  small  doses  of  the  saline 
laxatives,  such  as  the  natural  Carlsbad  (Sprudel)  ^^■ater,  the 
Rubinat  Condal  water,  or  artificial  solutions  of  sodium  sul- 
phate or  phosphate,  and  sometimes  the  bitter  waters  (mag- 
nesium sulphate  natural  waters  or  solutions),  and  in  cases  not 
too  depressed  or  debilitated  you  will  be  justified  in  making  a 
trial  of  them  for  the  double  purpose  of  helping  to  remove  the 
catarrhal  process,  thus  obviating  one  chief  obstacle  to  the  cure 
of  the  constipation,  and  keeping  the  bowels  open  meanwhile. 
In  the  more  asthenic  cases,  however,  especially  those  with 
deficient  gastric  secretion,  the  alkaline  waters  and  drugs  will 


CONSTIPATION  'J^'J 

be  likely  to  disagree  and  the  more  tonic  sodium  chloride 
waters,  such  as  those  of  Kissingen  and  Homburg,  will  then 
agree  better. 

In  any  case  when  a  teaspoonful  of  Carlsbad  salt  or  of 
sodium  sulphate,  or  a  mixture  containing  sodii  bicarb.,  5^  to 
oss.;  sod.  sulph.,  oss.  to  5j,  and  sod.  phos.,  oss.  to  oj ;  all  dis- 
solved in  a  glass  of  hot  water,  or  an  equivalent  dose  of  the  nat- 
ural waters,  fails  to  keep  the  bowels  open  with  the  hygienic  and 
mechanical  helps  mentioned,  it  will  not  be  desirable  to  admin- 
ister large  doses  of  them  for  long  periods,  even  in  the  presence 
of  catarrhal  complications.  You  should,  then,  instead,  continue 
them  in  the  same  small  dose,  provided  they  agree  ( not  produc- 
ing irritation)  ;  and  as  auxiliaries,  besides  plenty  of  drinking 
water,  give  the  oil  or  saline  enemas  already  mentioned.  Then, 
if  need  be,  give  one  of  the  forms  of  local  stimulation  above  re- 
ferred to,  of  which  the  simplest  and  most  effective  is  vibration 
applied  within  the  rectum  for  two  minutes  daily. 

The  milder  the  case  of  an  associated  chronic  intestinal 
catarrh,  the  more  nearly  the  treatment  may  approach  to  that 
required  for  simple  atonic  constipation,  from  which  it  doubt- 
less may  sometimes  result ;  but  in  the  pronounced  catarrhal 
cases,  the  diet  must  be  blander  and  more  concentrated,  includ- 
ing more  lean  beef  and  avoiding  all  coarse,  irritating  articles. 

For  further  details  as  to  the  diet  and  other  treatment  ap- 
propriate to  catarrhs  of  the  alimentary  canal,  see  the  previous 
lectures  devoted  to  those  diseases. 

Do  not  overlook  the  fact,  in  prescribing  remedies  for  one 
part  of  the  alimentary  canal,  that  they  may  act  injuriously  upon 
another  part.  For  example,  such  drugs  as  belladonna  and 
Carlsbad  salts,  as  well  as  some  of  the  foods,  such  as  sugar  and 
the  fats  or  oils,  which  are  useful  for  their  laxative  effect  (not 
to  mention  the  value  of  Carlsbad  water  or  salt  also  for  their 
alterative  effect  in  catarrhal  affections),  have  a  very  positively 
depressing  effect  upon  gastric  secretion,  lessening  the  quantity 
and  strength  of  the  gastric  juice.  These  effects  have  been 
confirmed  repeatedly.     In  fact,  any  physician  who  does  not 


"jy^  THE    GASTRO-INTESTINAL    CLINIC 

test  the  stomachs  of  his  chronic  invahd  patients  occasionally,  as 
to  their  secretory  work,  should  avoid  drugs  as  much  as  possible 
afld  depend  mainly  upon  hygienic  measures.  Even  then  his 
dietetic  prescriptions  may  often  disagree  with  the  stomach  in  a 
way  that  could  have  been  foreseen  and  prevented. 

In  cases  of  atonic  constipation  without  any  inflammatory 
complication,  or  after  curing  a  previously  existing  catarrh,  you 
should  usually  devote  your  first  and  your  chief  attention  to 
the  diet,  reducing  the  excess  of  meat  and  other  nitrogenous 
foods  which  most  constipated  persons  allow  themselves.  This 
nitrogenous  overplus  does  harm  in  various  ways  when  long 
continued,  but  what  concerns  the  present  discussion  mainly  is 
that,  when  taken  in  the  form  of  meat  or  eggs,  as  is  usually  the 
case,  it  does  not  leave  enough  residue  in  the  intestines  to  afford 
the  necessary  distention  and  mechanical  stimulation  to  provoke 
an  adequate  peristalsis.  A  considerable  proportion  of  cel- 
lulose, found  largely  in  the  grains,  vegetables,  and  in  many 
fruits,  is  absolutely  necessary  to  induce  regular  and  complete 
evacuations  of  the  bowels,  unless  one  is  to  depend  upon  physic. 

Some  of  the  less  acid  fruits,  such  as  figs  and  prunes,  have 
proved  in  my  experience  particularly  effective  in  overcoming 
constipation,  even  in  the  cases  very  often  of  the  spastic  form 
complicated  with  considerable  atony.  When  stewed  without 
sugar,  the  prunes,  especially,  agree  well  with  most  patients, 
even  taken  liberally,  though  they  may  increase  somewhat 
the  flatulence  in  large  eaters. 

Penzoldt's  Diet  for  Atonic  Constipation. — The  subjoined 
diet  table  for  uncomplicated  atonic  constipation  was  originally 
prescribed  by  Penzoldt  and  is  also  recommended  by  Boas : 

7  A.  M. — One  glass  of  water. 

8  A.  M. — A  generous  breakfast  with  sweetened  coffee,  much 
butter,  honey  and  Graham  bread  or  brown  bread  (pumper- 
nickel).    Thereafter  an  attempt  to  have  a  stool. 

I  P.  M. — Dinner  of  meat,  much  vegetables,  salads,  stewed 
fruit  (compot),  farinaceous  preparations  (mehlspeise),  one- 
half  bottle  of  light  wine — Moselle — or  cider. 


CONSTIPATION  7^9 

7  P.  M. — Meat  with  much  butter,  Graham  bread,  stewed 
fruit,  and  beer. 

lo  P.  M. — Before  going  to  sleep,  fresh  or  stewed  fruit. 

The  alcohohc  beverages  inchided  in  the  above  hst  are  not 
indispensable,  since  an  equivalent  amount  of  fruit  juice  would 
be  equally  effective  in  promoting  bowel  movements.  You 
should  also  bear  in  mind  that  in  numerous  diseases  which  are 
often  associated  with  constipation  both  the  decidedly  sweet 
and  sour  articles  of  such  a  typical  laxative  diet,  as  well  as  the 
excessive  amount  of  indigestible  material  in  the  form  of 
cellulose  as  in  many  of  the  vegetables  and  raw  fruits,  are  likely 
to  aggravate  and  are,  therefore,  positively  contra-indicated. 
Boas  calls  attention  to  this  himself  and  mentions  among  the 
diseases  in  which  such  a  diet  is  contra-indicated  the  following: 
diabetes  mellitus,"  obesity,  atony  or  dilatation  of  the  stomach, 
hyperacidity,  gastric  ulcer,  cancer  of  the  stomach  or  intestines, 
and  excessive  flatulence.  My  own  experience  fully  bears  out 
the  statement  of  Boas  as  to  the  unsuitableness  of  the  diet 
scheme  above  given  in  the  presence  of  the  diseases  just 
named  as  well  as  in  pronounced  catarrhal  inflammation  of 
any  part  of  the  alimentary  canal  and  in  ulceration  of  the 
intestines. 

The  ultra  adherents  of  the  meat-and-hot-water  regimen, 
which  often  proves  efficient  during  short  periods  in  the  treat- 
ment of  chronic  catarrhal  inflammations  of  the  alimentary 
canal,  have  preached  constantly  against  starch  and  led  thus  to  a 
popularization  of  the  foolish  notion  that  starchy  foods  are  to 
be  carefully  avoided  in  all  the  derangements  of  the  digestive 
system.  On  the  contrary,  except  in  the  catarrhal  cases  (when 
for  a  few  weeks  at  a  time  the  starches  and  sugar  may  be  greatly 
restricted),  there  are  few  such  derangements  in  which  a  mixed 
diet,  with  a  due  proportion  of  the  carbohydrates,  is  not  prefer- 
able in  the  long  run.  It  is  necessary,  as  not  only  promoting 
more  thorough  elimination  through  the  bowels,  but  also  as 
better  supplying  the  needs  of  nutrition.  When  not  otherwise 
contra-indicated  or  found  to  disagree,  the  fats  in  the  form  of 


ySO  THE    GASTRO-INTESTINAL    CLINIC 

fresh  cream,  butter  or  olive  oil,  and  also  sugar,  especially  sugar 
of  milk,  if  taken  rather  liberally  by  constipated  persons,  will 
greatly  conduce  to  freer  stools.  Many  patients  can  drink 
coffee  with  apparent  impunity,,  and  it  often  exerts  a  slight 
laxative  effect.  Tea,  chocolate,  cocoa  and  milk,  and  claret 
tend  to  increase  constipation,  as  a  rule,  to  which  there  are 
occasional  exceptions.  Cold  water,  taken  one  or  two  tumbler- 
f uls  several  times  a  day — upon  arising,  at  bedtime,  and  between 
meals — often  helps  to  overcome  atonic  constipation.  The  ad- 
dition of  five  to  ten  grains  of  table  salt  to  each  tumblerful  of 
water  increases  its  efficacy,  except  in  hyperchlorhydria,  when 
soda  or  some  other  alkali  should  replace  the  salt. 

Next  in  importance  after  the  diet  comes  exercise  in  the  open 
air.  Patients  who  have  been  stubbornly  constipated  while 
leading  sedentary  lives,  often  recover  spontaneously  after  en- 
gaging in  outdoor  occupations,  or  through  spending  several 
hours  daily  in  such  recreations  as  horseback  riding,  rowing, 
golfing,  or  lawn-tennis,  though  prolonged  and  excessive  horse- 
back-riding, as  in  the  case  of  cavalrymen,  has  been  observed  to 
produce  constipation.  Bicycling  sometimes  effects  a  cure,  but 
less  frequently. 

Changes  of  climate  involving,  as  they  usually  do,  rest  from 
mental  or  nervous  strain,  and  especially  when  prudent  sea- 
bathing or  mountain  climbing  is  added,  often  promptly  relieve 
constipation.  When  these  things  are  not  practicable,  good 
results  may  usually  be  obtained  from  systematic  movements  of 
the  trunk  muscles  and  a  course  of  hydriatic  treatment  carefully 
adapted  to  the  case.  Reference  has  already  been  made  to 
the  exercises  that  may  be  practiced  by  patients  in  a  well-venti- 
lated bedroom;  and  the  douches  or  sponge  baths  with  tepid  or 
cold  water,  that  may  be  taken  in  any  bathroom,  will  frequently 
prove  effective  in  connection  with  appropriate  diet.  Cold 
affusions  or  douches  do  not  suit  well  in  the  spastic  cases;  and 
the  same  may  be  said  of  abdominal  massage,  which,  though  it 
aggravates  the  spastic  form,  may  be  a  very  useful  factor  in  the 
treatment  of  atonic  constipation,  given  by  the  physician  him- 


CONSTIPATION  781 

self  (when  he  is  competent  to  give  it),  or  by  a  thoroughly 
expert  masseur  under  his  personal  supervision. 

But  massage  of  the  abdomen,  like  gymnastics,  can  only 
very  gradually  overcome  even  atonic  constipation  by  develop- 
ing and  strengthening  the  muscles  involved  in  the'  act  of 
defecation.  Except,  therefore,  in  the  cases  in  which  the  diet, 
with  a  liberal  use  of  drinking  water,  effects  a  speedy  improve- 
ment, this  form  of  constipation  recjuires  time  to  cure — nearly 
always  months  and  sometimes  a  year  or  more.  For  the  small 
proportion  of  incurable  cases  of  constipation  in  which  enemas 
of  some  bland  oil  do  not  procure  sufficient  evacuations,  the  best 
laxative  drugs  are  cascara,  aloes,  senna,  and  sulphur,  in  their 
smallest  efficient  doses.  Phenolphthalein  in  doses  of  one  to 
three  or  four  grains  daily  has  been  lately  proved  of  value  in 
atonic  constipation. 

The  treatment  of  the  spastic  form  resolves  itself  mainly  into 
the  cure  of  the  neurasthenia  or  hysteria  upon  which  it  depends. 
When  this  is  severe  in  type,  the  usual  method  by  rest,  seclusion, 
and  generous  feeding  is  applicable,  except  that  massage  of  the 
abdomen  must  be  omitted,  and  that  the  milk  diet  disagrees 
when  there  is  much  dilatation  or  even  marked  atony  of  the 
stomach. 

Notwithstanding  the  excessive  irritability  of  the  intestines, 
a  bulky  diet,  including  a  liberal  allowance  of  vegetables  and 
fruit,  is  usually  helpful  here  as  in  the  atonic  form,  when  not 
otherwise  contra-indicated.  Not  only  is  massage  of  the  ab- 
domen to  be  avoided  in  the  spastic  type,  but  stimulating  af- 
fusions or  jet  douches  of  cold  water  to  the  same  part  are 
likely  to  aggravate,  and  our  German  confreres  generally  insist 
that  purgatives  are  equally  harmful.  My  own  experience  con- 
firms all  these  observations.  Good  results  may  be  expected 
from  the  usual  building-up  measures,  including  systematic  ex- 
ercises and  tonics,  except  that  possibly  iron  may  increase  the 
constipation,  and  even  strychnine  and  the  other  tetanizers  may 
have  a  like  effect  in  this  form  unless  given  in  small  doses. 
Warm  jet  douches  to  the  abdomen  are  recommended  by  West- 


782  THE    GASTRO-INTESTINAL    CLINIC 

phalen,  who  also  insists  that  opium  and  belladonna  in  these 
cases  will  often  produce  more  copious  evacuations  than  purga- 
tives. The  same  author  advises  bromides,  with  small  doses 
of  chloral,  for  more  prolonged  use,  to  overcome  the  irregular 
intestinal  contractions.  With  regard  to  belladonna  and 
atropine,  there  are  numerous  observations  attesting  their  ef- 
ficacy in  various  forms  of  constipation,  and  even  in  ob- 
struction from  irregular  spasmodic  muscular  action,  intestinal 
cramps  of  different  degrees  of  severity;  but  it  needs  to  be 
constantly  borne  in  mind  that  in  overcoming  by  these  rem- 
edies a  spastic  constipation  associated  with  hypopepsia — dys- 
pepsia from  deficient  gastric  juice — the  latter  condition  will 
necessarily  suffer  an  aggravation  that  may  be  serious,  though 
this  result  might  be  avoided  by  administering  HCl  and  pep- 
sin after  meals  at  the  same  time.  In  cases  of  spastic  con- 
stipation with  persistently  excessive  contraction  of  the  anal 
sphincter,  the  latter  should  be  dilated  either  quickly  under 
ansesthesia,  or  gradually  by  dilators. 

Olive  oil,  both  by  the  mouth  and  by  enema  (especially  the 
latter),  is  a  safe  and  generally  efficient  resource  in  stubborn 
cases  of  the  spastic  form.  I  have  recently  seen  curative  results 
in  cases  of  constipation  from  the  use  of  various  preparations 
made  from  coal  oil  such  as  vaselin,  albolene,  Purpetrol  given 
internally.  Teaspoonful  to  tablespoonful  doses  of  either,  taken 
once  or  twice  a  day,  often  succeed  in  mild  cases;  but  these 
petroleum  preparations  seem  to  depress  the  heart  a  little  in  some 
cases  when  used  long,  and  even  Purpetrol,  the  purest  of  them 
all,  will  bear  watching. 

In  the  spastic,  even  more  than  in  the  atonic,  form  of  con- 
stipation, the  greatest  help  may  be  derived  from  changes  of 
climate  and  an  out-of-door  life,  except  in  the  case  of  the  worst 
neurasthenics  and  hysterics,  who  require  rest  at  first.  Then, 
as  in  all  nervous  affections,  every  case  needs  to  be  studied  by 
itself.  There  is  no  class  of  diseases  in  which  routine  methods 
are  more  likely  to  fail. 

The  best  progress  will  be  made  when  the  state  of  the  gastric 


CONSTIPATION  783 

function,  both  secretory  and  motor,  is  carefully  studied.  The 
cases  with  markedly  deficient  peptonization  will  often  gain  as 
much  by  the  administration  of  HCl  and  pepsin  after  meals  as 
the  opposite  class  of  cases  are  sure  to  be  injured  and  ag- 
gravated by  such  a  line  of  medication. 

Great  regularity  in  observing  fixed  times  for  eating  and 
for  defecation  is  extremely  important.  Various  observers 
have  noted  the  clinical  fact  that  lavage  will  sometimes  cure 
constipation.  Spivak  has  recently  called  attention  anew  to 
this  and  claims  priority  for  the  original  observation.  He  has 
found  lavage  useful  ( i )  in  constipation  due  to  excessive 
acidity;  (2)  in  the  same  due  to  gastric  atony;  (3)  in  diarrhea 
from  excessive  mucus  in  the  stomach,  and  (4)  in  obstruction 
of  the  intestines,  from  whatever  cause.  I  have  employed 
lavage  coincidently  with  other  measures  in  a  great  many  cases 
of  constipation  from  various  causes,  and  have  occasionally  seen 
the  latter  symptom  relieved  by  it. 

Flushing  the  colon  with  large  quantities  of  water  or  aqueous 
solutions  of  drugs  may  be  useful  for  short  periods,  but  as  a 
means  of  emptying  the  bowels  regularly  in  stubborn  cases  of 
chronic  constipation,  which  have  proved  refractory  to  curative 
treatment,  is  to  be  condemned.  It  is  sure  in  time  to  aggravate 
the  disease,  causing  a  gradually  increasing  paresis  and  dilata- 
tion of  the  colon,  even  more  surely  than  a  dependence  on  the 
daily  use  of   a  laxative  medicine. 

In  spastic  constipation  Abrams  advises  stimulation  by  a 
strong  sinusoidal  current  or  by  concussion  (performed  by  a 
succession  of  blows  with  a  little  hammer  called  a  concussor) 
of  the  spine  of  the  eleventh  dorsal  vertebra;  in  atonic  con- 
stipation he  treats  in  the  same  way  the  first  three  lumbar  verte- 
brae, but  in  this  form  finds  concussion  the  more  effective.  See 
page  311.^ 

See  Lecture  XXVII.  for  details  of  the  technique  of  various 
forms  of  local  treatment  of  the  colon  by  injections  of  oil,  medi- 
cated aqueous  solutions,  etc. 

^Spondylotherapy.     Philopolis  Press,  San  Francisco,  1910, 


LECTURE  LXXI 
DIARRHEA 

Etiology. — The  symptom  diarrhea  is  most  frequently  a 
consequence  of  catarrhal  inflammation  of  the  mucosa  in  some 
portion  of  the  bowel,  but  may  result  from  constipation  both 
through  the  direct  irritation  of  the  mucous  and  the  muscular 
coats  of  the  intestines  by  the  retained  and  hardened  fecal 
masses,  and  by  the  irritating  influence  upon  the  same  of  the 
gases  which  are  caused  by  decomposition  in  such  feces.  Diar- 
rheas thus  produced  soon  develop  into  true  inflammation — 
enteritis — after  frequent  recurrences,  especially  when  neglected, 
or  treated,  as  so  often  happens,  by  astringents  and  opiates. 
Frequent  loose  stools  may  also  depend  upon  poisons,  etc., 
in  the  blood,  as  in  uraemia,  lithsemia,  malaria,  and  various 
acute  diseases.  They  often  owe  their  origin  to  fermentation 
in  the  stomach  in  consequence  of  the  absence  or  deficiency  of 
HCl,  as  in  chronic  gastritis,  especially  the  atrophic  form  with 
achyha,  and  of  the  digestive  ferments  in  the  gastric  juice. 
They  occur  usually  in  the  later  stages  of  morbid  growths  in 
or  adjacent  to  the  intestines,  though  sometimes  in  fhese  cases 
constipation  persists  almost  to  the  end.  Diarrhea  occasionally 
seems  to  have  no  other  cause  than  a  nervous  derangement  in- 
volving the  peristaltic  apparatus.  The  feces  are  then  propelled 
so  rapidly  that  they  do  not  have  time  to  harden  by  the  absorp- 
tion of  their  liquid  contents.  The  loose  movements  may  also 
depend  u\)C)n  either  an  increased  secretion  or  diminished  power 
of  absorption,  both  of  which  conditions  may  result  from  faulty 
innervation  as  well  as  from  other  causes.  Diarrhea  is  an 
almost  constant  accompaniment  of  tuberculous,  syphilitic,  and 

784 


DIARRHEA  783 

simple  ulceration  of  the  bowels,  especially  when  the  colon  is 
affected. 

Chronic  catarrhal  inflammation  involving  the  appendix 
alone,  or  with  only  a  slight  and  occasional  implication  of 
other  portions  of  the  gut,  is  probably  responsible  for  many 
otherwise  inexplicable  recurrent  attacks  of  bowel  looseness. 
I  have  often  observed  such  attacks  in  persons  presenting  signs 
of  a  thickened  and  somewhat  tender  appendix,  but  without 
evidences,  in  the  intervals,  of  enteritis  elsewhere,  and  sometimes 
no  such  evidences  appeared  even  during  the  attacks;  and  the 
latter  could  not  be  traced  to  any  of  the  ordinary  causes. 

It  is  well  known  that  bacteria  grown  in  closed  cavities  are 
likely  to  be  excessively  virulent,  and  it  is  probable  that  the 
colon  bacilli,  which  are  from  time  to  time  forcibly  expelled 
into  the  cecum  through  the  stenosed  orifice  of  a  catarrhal  ap- 
pendix, may  be  virulent  enough  to  set  up  a  decided  irritation 
of  the  colon  with  or  without  the  production  of  a  catarrhal 
process  there. 

Chronic  enteritis,  involving  a  portion  at  least  of  the  colon, 
and  often  much  of  the  small  intestine  as  well,  is,  however, 
with  sometimes  ulceration  as  a  complication,  the  most  frequent 
cause  of  a  persistent  diarrhea.  When  enteritis  exists,  you  will 
be  able  to  find  at  times  mucus  in  the  stools,  either  coating  the 
occasional  formed  portions  on  the  outside,  showing  its  origin 
low  down  in  the  colon  or  rectum,  or  more  commonly  mixed 
with  the  feces  more  or  less  intimately,  coming  then  from 
higher  up  in  the  bowel.  .  Usually,  too,  by  deep  palpation 
gently  made,  you  will  find  sensitive  regions  over  the  course 
of  the  colon,  especially  over  the  transverse  portion  and  the 
cecum. 

The  treatment  of  diarrhea  divides  itself  naturally  into 
dietetic,  mechanical,  and  medicinal,  and  the  medicines  useful 
in  the  disease  include  eliminants,  alkalies,  and  antiseptics, 
with  sometimes  sedatives  and  astringents. 

In  an  acute  attack  of  loose  bowels,  or  one  which  has  existed 
only  a  few  days,  it  is  usually  not  necessary  to  do  anything  ex- 


786  THE   GASTRO-INTESTINAL    CLINIC 

cept  to  insist  upon  rest,  and  either  abstinence  from  food  or  a 
limitation  to  the  smallest  quantities  of  the  blandest  possible 
nourishment,  such  as  fresh  meat  juice  or  boiled  milk  with 
boiled  rice,  though  the  remedies  to  be  first  administered  in  a 
doubtful  chronic  case,  as  recommended  below,  will  often  hasten 
the  cure. 

To  give  you  the  most  practical  instruction  in  the  clearest 
manner,  I  will  advise  you  how  one  may  best  proceed  in  a  case 
of  diarrhea  which  has  persisted  a  number  of  da3^s,  or  weeks,  or 
longer,  in  a  patient  not  tuberculous  nor  syphilitic,  not  acutely 
ill  in  any  way,  and  not  having  a  palpable  tumor  in  the  abdo- 
men. If  the  stools  are  very  offensive  (or  if  they  contain 
scybala,  with  or  without  mucus),  begin  with  a  moderate  or 
small  dose  of  some  gently  acting  laxative,  preferably  a  tea- 
spoonful  to  a  tablespoonful  of  castor  oil,  but  an  equivalent 
dose  of  rhubarb  or  a  saline  will  answer  the  purpose.  When 
the  tongue  is  foul  and  the  breath  bad,  follow  with  grain  1-20 
to  1-6  of  calomel,  given  every  hour  or  two  till  the  stools  be- 
come less  offensive  and  of  a  yellow  color.  If  there  should  be 
nausea  or  an  irritable  stomach,  it  would  be  better  to  omit  the 
oil  and  begin  at  once  with  the  smallest  mentioned  doses  of 
calomel,  given  every  hour  at  first,  and  later  every  two  or  three 
hours.  This  is  usually  the  better  plan,  in  the  case  of  children 
especially.  These  will,  in  a  few  days,  often  control  both  the 
gastric  and  intestinal  trouble  without  any  other  measures  ex- 
cept rest  and  diet,  as  advised  above  for  an  acute  or  recent 
attack. 

Should  the  laxati<\'es  not  have  removed  all  fetor,  scybala, 
and  undigested  pieces  of  food  from  the  stools  by  the  end  of 
two  days,  it  will  usually  be  desirable  to  give  oil  or  rhubarb  a 
second  time,  unless  there  should  be  pain  or  other  signs  of  ir- 
ritation produced  by  the  remedies,  which  rarely  happens, 
except  when  excessive  doses  have  been  administered.  In  the 
event  of  such  irritation,  give,  instead  of  more  laxatives,  ,5-  to 
20-grain  doses  of  bismuth  subnitrate  after  every  loose  stool ; 
and  a  day  or  two  later,  if  all  the  symptoms  have  not  been 


DIARRHEA  •  787 

removed,  repeat  the  laxative  and  continue  cautiously  this 
method  of  elimination  with  the  addition  of  bismuth  after 
stools,  and  opium  if  needed  for  severe  pain,  until  by  careful 
inspection  of  the  evacuations  and  deep  palpation  over  the  colon, 
you  have  determined  that  all  stagnant  and  decomposing  re- 
mains of  food  or  feces  have  been  removed. 

In  the  great  majority  of  cases,  including  usually  all  those 
dependent  upon  an  underlying  condition  of  constipation,  which 
has  led  to  accumulations  of  hardened  feces,  with  often  patches 
of  inflammation  of  the  mucosa,  such  a  course  of  laxatives  con- 
tinued for  a  few  days  with  a  little  bismuth  at  the  last,  com- 
bined with  chalk  wdien  the  stools  are  very  acid,  will,  without 
any  opium  or  active  astringent,  be  found  to  have  controlled 
the  diarrhea.  You  will  need  then  to  apply  yourselves  to  the 
more  difiicult  task  of  overcoming  the  underlying  condition  of 
constipation,  for  which,  besides  diet  and  special  exercises, 
massage  and  electricity  will  serve  you  best,  as  I  have  de- 
scribed in  Lecture  LXX.  The  cases  in  which  constipation  has 
gone  on  to  the  development  of  a  persistent  diarrhea,  will  usu- 
ally present  more  or  less  intestinal  catarrh,  and  both  the 
constipation  and  its  resultant  diarrhea  w^ill  then  be  best  treated 
by  remedies  addressed  to  the  pathologic  change. 

In  certain  cases  the  bowels  can  be  emptied  better  by  a  thor- 
ough flushing  of  the  colon  from  below  than  by  purgatives,  and, 
generally  speaking,  the  more  strictly  the  disease  is  limited  to 
the  large  intestine,  and  the  longer  the  accumulation  of  feces  has 
been  going  on,  the  greater  the  advantages  of  this  method 
of  removing  the  cause,  provided  it  be  not  continued  too 
long. 

Complicating  Conditions. — But  in  a  certain  proportion  of 
these  cases,  even  after  the  intestines  have  been  cleared  of  fecal 
masses,  decomposing  ingesta,  irritating  secretions,  etc.,  fre- 
quent thin  stools  will  persist.  In  such  cases,  you  should  test  the 
stomach  contents  to  see  whether  the  gastric  juice  is  sufficiently 
active,  and  proceed  to  remedy  any  deficiency  discovered. 
You    should    also    study    the   urine    carefully,    to    detennine 


788  THE    GASTRO-INTESTINAL    CLINIC 

whether  the  uratic  diathesis  or  some  other  toxsemic  state  is 
not  answerable  for  the  persistent  flux.  You  may  find  that  a 
latent  nephritis  is  at  the  bottom  of  the  trouble,  the  kidneys 
failing  to  do  their  excretory  work  thoroughly,  thus  imposing 
more  upon  the  bowels;  and  in  all  these  self-poisoning  cases 
you  will  readily  see  what  mischief  must  be  wrought  by  the  cus- 
tomary method  (which  fortunately  generally  fails)  of  trying 
to  check  diarrhea  with  opium  and  astringents. 

The  Appendix  Often  Involved  in  Diarrhea. — You  will  also 
examine  thoroughly  to  see  that  there  is  not  a  tender,  swollen 
appendix  sending  out  its  colonies  of  virulent  colon  bacilli,  or 
a  cirrhotic  liver,  or  feeble,  laboring  heart  causing  an  obstructed 
circulation  in  the  abdominal  vessels,  or  that  widely  prevalent 
affection  in  women  especially,  a  downward  displacement  of 
one  or  more  of  the  abdominal  viscera,  which  has  been  the  dis- 
turbing cause,  producing  at  first,  as  such  conditions  usually 
do,  constipation,  followed  by  its  very  frecjuent  sequel — diarrhea. 

Any  such  factor  in  the  causation  will,  of  course,  need  to  re- 
ceive a  large  share  of  attention  in  the  treatment ;  and  nearly 
always  some  one  of  them  can  be  found,  if  searched  for  with 
the  necessary  care  and  skill.  AMiatever  else  may  be  wrong,  the 
liver  is  generally  embarrassed  in  chronic  diarrhea,  and  a  use- 
ful addition  to  other  appropriate  remedies  will  be  very  small 
alterative  doses  of  podophyllin — grain  1-200  to  grain  i-ioo 
every  three  to  four  hours — too  small  a  dosage  to  increase  peri- 
stalsis, in  adults  at  least,  and  yet  seemingly  enough  to  exert  a 
curative  influence  upon  many  cases  of  diarrhea  with  profuse, 
thin  stools.  It  is  particularly  effective  in  the  so-called  morning 
diarrhea,  in  which  there  are  one  or  more  loose  and  usually 
painless  stools  every  morning,  with  no  further  trouble  during 
the  day.  (See  Lecture  XXXIV.)  I  have  controlled  numerous 
previously  stubborn  cases  of  this  kind  l)y  i-120-grain  doses  of 
podophyllin,  assisted  only  by  a  bland,  digestible  diet ;  but  when 
this  alone  does  not  prove  promptly  effective,  I  am  accustomed 
to  prescribe  in  addition  for  any  chronic  form  of  looseness,  de- 
pendent upon  excessive   secretion,   or  an   irritated   intestinal 


DIARRHEA  789 

mucosa    from    fermentation,   some   such   combination   as    the 
following : 

B  Bismuth  subnit.  vel.  salicylat.  \ 

Ichthalbin  |- , aa  3  ii 

Cretae  preparat.  ) 

M.  et  ft.  chart.     No.  XII. 
Sig.     One  in  water  after  every  loose  stool. 

But  before  prescribing  the  above,  or  any  astringent,  clear 
out  the  bowel  by  a  mild  physic. 

When  the  looseness  depends  upon  a  pronounced  chronic 
colitis,  the  remedies  can  often  be  applied  to  the  best  advantage 
per  rectum.  Once  a  day  at  first,  and  later  every  other  day 
until  the  flux  ceases,  place  the  patient  upon  the  back,  or  first 
upon  the  left  side  for  a  few  minutes,  and  after  that  upon  the 
right  side,  with  the  hips  a  little  raised,  and  after  a  preliminary 
cleansing  of  the  colon  by  introducing  a  normal  salt  solution, 
or  a  weak  solution  of  sodium  bicarbonate  ( 3  i  to  Oii)  at  a 
temperature  of  about  100  to  105°  F.,  a  quart  at  a  time,  repeated 
until  it  comes  away  without  the  color  or  odor  of  feces,  inject 
a  pint  of  water  at  90°  containing  a  dram  of  bismuth  in  suspen- 
sion, and  let  it  remain  as  long  as  it  will.  In  bad  cases  it  is 
well  to  supplement  this  by  injecting,  two  or  three  times  a 
week,  some  decided  astringent,  such  as  nitrate  of  silver  (grain 
iii  to  Oi)  ;  or  an  antiseptic  solution  such  as  one  and  a  half 
drams  of  strong  carbolic  acid  dissolved  in  three  ounces  each  of 
glycerin,  and  glycothymoline  or  listerine,  of  which  an  ounce  is 
then  added  to  two  quarts  of  tepid  or  warm  water  for  one 
clyster.     (See  Lecture  LXVI.) 

When  the  bowel  will  not  tolerate  enemas  well,  but  con- 
tracts at  once  spasmodically,  there  is  often  some  morbid  con- 
dition discoverable  in  the  rectum  or  prostate  gland,  or,  in  the 
case  of  women,  in  the  internal  genitals,  which  should  be  sought 
for  and  remedied.  In  such  cases  the  treatment  can  generally 
be  carried  out  in  spite  of  the  difficulty,  by  placing  the  fountain 
syringe  or  other  reservoir  containing  the  solution  not  more 
than  one  or  two  feet  above  the  patient,  so  as  to  lessen  the 


790  THE    GASTRO-INTESTINAL    CLINIC 

pressure,  and  in  addition,  when  necessary,  by  raising  some- 
what the  temperature  of  the  hquid.  Such  medicated  clysters 
often  help  much  in  the  cure  of  an  intestinal  catarrh,  but  should 
never  be  continued  long  as  a  routine  method  of  evacuating  the 
bowels  in  stubborn  constipation. 

The  diet  in  chronic  diarrhea  needs  to  be  most  carefully 
studied,  for  it  is  a  difficult  problem  often  to  nourish  the  patient 
sufficiently  w^ithout  permitting  a  greater  variety  of  aliment 
than  can  be  taken  without  aggravating  the  disease.  Milk  in 
some  of  its  forms  can  usually  be  made  to  agree,  and  we  may 
allow  well-cooked  rice,  freshly  toasted  bread,  zwieback  (if  not 
too  hard),  or  other  partly  dextrinized  starch  food,  though 
sometimes  good  home-made  stale  bread  agrees  even  better. 

In  many  cases  soft-boiled  or  raw  eggs  are  borne  well,  and 
in  nearly  all,  the  whites  of  eggs.  Baked  white  potatoes  and 
some  of  the  vegetable  purees  may  be  cautiously  tried  in  the 
less  severe  cases,  and  often  buttered  stale  bread  can  be  added. 

In  certain  cases  in  which  there  is  very  excessive  fermentation, 
beginning  in  the  stomach,  and  yet  sufficient  gastric  juice,  or  the 
possibility  of  supplementing  it  well  enough  by  administering 
HCl  and  pepsin,  the  most  satisfactory  basis  of  the  diet  at 
first — for,  say,  three  or  four  weeks — is  finely  chopped  beef,  with 
a  free  use  of  hot  water  still  further  to  stimulate  the  secretion  of 
the  digestive  glands.  Give  with  these  only  two  or  three  slices 
of  stale  or  toasted  bread  daily,  and  a  very  small  amount  of  as- 
paragus tips,  spinach,  or  a  leaf  or  two  of  lettuce  merely  as  a 
relish,  gradually  adding  more  carbohydrates  and  fats  as  they 
are  found  to  be  tolerated. 

In  some  of  the  worst  cases  the  diet  may  have  to  be  limited 
for  a  while  to  peptonized  milk  or  other  predigested  foods,  such 
as  Eskay's  Food,  etc.,  and  in  others,  Plasmon,  with  the  help 
of  some  one  of  the  meat  powders,  answers  best.  Boiled  rice 
with  boiled  milk  makes  a  good  combination  for  some  severe 
cases. 

The  foods  which  are  most  likely  to  aggravate  diarrhea  are 
first  of  all   the  raw  fruits,  and  the  sourer  the  worse,  next  the 


DIARRHEA  79 1 

cooked  fruits,  especially  when  sweetened,  and  third  the  crude 
succulent  vegetables.  In  some  cases  no  vegetables  can  be  made 
to  agree.  Sugar  in  any  form,  as  well  as  hot  or  fresh  yeast 
bread,  and  the  shell  fish,  are  badly  borne  as  a  rule.  Milk, 
which  usually  suits  best,  will  occasionally  increase  diarrhea, 
though  it  is  less  likely  to  do  so  if  boiled,  sterilized,  or  pepton- 
ized, and  even  soft-boiled  eggs  are  not  always  well  digested 
by  these  patients. 

The  suitability  of  a  diet  must  be  judged  by  its  effects  upon  the 
frequency  of  the  stools  and  the  amount  of  fermentation  as 
shown  by  the  stomach  contents  and  feces,  as  well  as  by  the 
amount  of  indican  and  aromatic  sulphates  in  the  urine. 

In  the  diarrheas  resulting  from  chronic  catarrh  of  the  ap- 
pendix, the  same  treatment  applies  as  in  those  from  other 
forms  of  intestinal  catarrh,  except  that  it  is  even  more  im- 
portant in  them  to  keep  the  colon,  especially  the  cecum,  free  of 
fecal  accumulations  and  as  aseptic  as  may  be.  Counter-irrita- 
tion, by  iodine  or  otherwise,  over  the  appendix  is  helpful,  and 
small  alterative  doses  of  calomel  can  be  advantageously  con- 
tinued during  two  days  of  each  week,  for  a  month  at  a  time, 
provided  there  be  one  or  two  complete  (but  not  necessarily 
loose)  evacuations  daily.  Moderate  doses  of  galvanism  (15  to 
30  ma.)  may  also  be  applied  locally  through  the  cecum  from 
side  to  side.  • 

For  persons  thus  affected  who  are  not  able  or  willing  to  diet 
strictly  and  persist  faithfully  with  the  above-outlined  treat- 
ment, the  operation  of  appendectomy  should  be  performed. 

In  the  comparatively  infrequent  diarrheas  dependent  upon 
other  causes  than  indigestion,  constipation,  intestinal  catarrhs, 
and  toxaemias,  opium  and  astringents  may  at  times  be  needed ; 
but  great  caution  should  be  exercised  not  to  resort  to  them 
until  the  latter  varieties  of  the  affection,  requiring  generally 
the  opposite  method — elimination — can  be  positively  excluded, 
and  such  mild  antiseptics  and  astringents  as  bismuth  should  al- 
ways first  be  tried. 

Finally,  in  all  the  forms  of  chronic  diarrhea,  the  general 


792  THE    GASTRO-INTESTINAL    CLINIC 

health  should  be  built  up  in  all  possible  ways,  by  an  abundance 
of  outdoor  air,  changes  of  climate  at  times,  proper  clothing, 
and  a  judicious  use  of  water  locally.  It  is  a  very  debilitating 
disease,  and  other  debilitating  conditions  aggravate  it.  To 
cure  obstinate  cases,  the  mode  of  life  must  be-  hygienic  in  all 
respects. 

The  Nervous  Forms  of  Diarrhea  following  grief,  fright,  or 
any  intense  emotion,  or  from  any  nervous  derangement,  are 
usually  transient  in  duration,  but  chronic  cases  do  occur. 
These  demand,  in  addition  to  the  general  treatment  of  neu- 
rasthenia, nerve  sedatives  with,  in  the  more  stubborn  cases, 
bismuth,  or  even  the  stronger  astringents,  and  sometimes  some 
one  of  the  opiates. 

When  fermentation  in  the  stomach  or  small  intestine  causes 
excessive  acidity,  the  cure  of  the  resulting  or  complicating  diar- 
rhea will  usually  be  promoted  by  adding  to  the  other  treatment 
5-  to  20-grain  doses  of  prepared  chalk  several  times  a  day. 
The  addition  of  lime  water  to  the  milk  given  as  part  of  the  diet, 
helps  in  the  same  way  and  also  makes  the  milk  agree  better. 


LECTURE  LXXII 
DYSENTERY 

Definition. — The  term  dysentery  signifies  an  inflammatory 
condition  of  the  large,  and  sometimes  also  of  the  small,  in- 
testine accompanied  by  tenesmus  and  the  frequent  passage  of 
small  mucous  and  blood-stained  stools.  It  is  generally  con- 
sidered an  epidemic  disease,  but  may  occur  sporadically. 

.Etiology. — Each  variety  of  dysentery  has  a  cause  peculiar 
to  itself;  all  forms,  however,  have  certain  aetiologic  factors  in 
common. 

Dysentery  is  most  prevalent  in  the  tropics,  although  it  oc- 
curs both  epidemically  and  endemically  in  the  temperate  zone, 
where  it  exists  more  frecjuently  at  the  end  of  summer  and  in 
the  autumn.  In  the  tropical  districts  it  is  more  fatal  than 
cholera,  and  has  caused  more  deaths  in  armies  than  actual 
warfare.  Striimpel  states  that  in  the  Anglo-Indian  army  the 
mortality  due  to  dysentery  is  30  per  cent,  of  all  deaths.  The 
high  death-rate  of  this  disease  in  the  past  has  largely  been  due 
to  bad  hygiene  and  the  lack  of  proper  sanitary  regulations. 
Attention  has  been  called  by  Manson  to  the  tendency  of  dys- 
entery to  occur  in  malarial  districts.  The  manner  of  infec- 
tion has  not  been  positively  determined ;  evidence,  however, 
tends  to  point  to  the  water-supply,  flies,  and  the  fecal  dejec- 
tions of  either  the  sick  or  of  healthy  bacilli-carriers,  as  the  prin- 
cipal sources  of  the  specific  germ. 

Constipation,  and  gastro-intestinal  disturbances  brought 
about  by  the  ingestion  of  bad  food,  especially  unripe  fruit, 
predispose  to  dysentery. 

793 


794  THE    GASTRO-INTESTINAL    CLINIC 

This  disease  occurs  at  any  age  and  in  either  sex.  There  is 
no  race  immunity,  although  Kieffer/  from  an  extended  ex- 
perience with  troops,  believes  that  the  American  negro  is 
relatively  immune  to  amoebic  and  bacillary  dysentery. 

A  classification  of  dysentery  into  the  following  varieties  has 
been  found  convenient :  catarrhal,  bacillary,  amoebic,  and 
chronic,  though  now  authorities  are  inclined  to  condense  all 
these  into  two  main  classes — bacillary  and  amoebic. 

CATARRHAL   DYSENTERY  (SPORADIC    DYSENTERY)^ 

This  is  an  acute  form  which  occurs  commonly  in  the  tem- 
perate zone. 

Etiology. — Catarrhal  dysentery  may  acco  npany  the  spe- 
cific intestinal  lesions  of  tuberculosis  and  typhoid  fever,  and  is 
sometimes  associated  with  the  acute  exanthems. 

Simple  irritants,  such  as  the  eating  of  green  fruit  or  other 
unwholesome  food,  and  exposure  to  a  chilly  night  air  after  a 
hot  day,  or  sleeping  on  damp  ground  may  cause  the  disease. 

Until  recently  no  specific  organism  was  associated  with  this 
type  of  dysentery,  but  in  an  epidemic  at  Hartwick,  N.  Y., 
Curtis  was  able  to  isolate  the  bacillus  pyocyaneus  in  large 
numbers  in  the  stools,  and  both  he  and  Kiefifer  now  consider 
this  micro-organism  as  an  important  setiologic  factor.  Catar- 
rhal dysentery  occurs  in  children  as  the  so-called  enterocolitis 
of  the  summer  months.  It  was  in  the  dejecta  of  such  cases 
that  Duval  and  Vedder^  found  the  bacillus  of  Shiga.  If  their 
researches  can  be  confirmed,  catarrhal  dysentery  will  here- 
after be  classed  as  a  form  of  bacillary  dysentery. 

Pathology. — The  morbid  process  is  usually  limited  to  the 
colon,  although  occasionally  the  lower  part  of  the  ileum  is 
invoh'ed.     The  mucosa  is  covered  with  a  bloody  mucus,  the 

"^  Phil  a.  Med.  Joiir.,  January  31,  1903. 

2  Recent  observations  make  it  probable  that  most  cases  hitherto  classed 
as  catarrhal  or  sporadic  dysentery  owe  their  origin  to  some  one  of  either 
the  Shiga-Kruse  or  Flexner  group  of  bacilli.     See  note  on  p.  808. 

^Jour.  Exper.  Med.,  February  5,  1902. 


DYSENTERY  795 

blood-vessels  are  injected,  and  the  solitary  follicles  have  un- 
dergone hyperplasia.  The  mucosa  is  eroded  and  the  seat  of 
superficial  ulcers. 

Symptoms. — A  prodromal  stage  lasting  a  day  or  two  may 
exist,  during  which  there  occur  slight  abdominal  pain,  ano- 
rexia, and  a  mild  diarrhea;  or  the  onset  may  be  sudden.  At 
first  there  is  a  copious  and  painless  diarrhea ;  soon  the  evacua- 
tions become  more  frequent  and  smaller  in  size ;  the  stools  are 
streaked  with  mucus  and  blood,  and  their  passage  is  accom- 
panied by  colicky  pains  (tormina)  and  straining  (tenesmus) . 
When  the  disease  is  fully  established,  the  amount  of  the  evacu- 
ations seldom  exceeds  a  tablespoonful.  They  consist  of  a  clear 
gelatinous  mucus,  streaked  or  tinged  with  blood.  Pus  may 
occasionally  be  present  in  them.  The  number  of  stools  varies 
in  mild  cases  from  five  to  ten,  and  in  severe  cases  from  thirty 
to  one  hundred  in  twenty-four  hours.  The  colicky  pain  may 
come  on  spontaneously,  or  after  the  ingestion  of  food,  or  even 
upon  moving  about  in  bed.  The  straining  is  a  most  distressing 
symptom ;  the  anus  becomes  inflamed  and  is  the  seat  of  intense 
pain,  and  the  bowel  may  be  prolapsed.  There  may  be  tenderness 
upon  pressure  along  the  course  of  the  colon.  The  disease  rarely 
begins  with  a  chill.  The  temperature  at  the  onset  is  generally 
slight,  but  may  range  between  102°  and  104°  F.  The  tongue  is 
coated,  at  first  moist,  then  dry,  and  at  last  it  may  become  red 
and  glazed.  The  skin  is  dry,  except  during  the  attacks  of 
tormina,  when  it  may  temporarily  be  moist.  The  pulse  may  be 
normal  in  the  mild  cases,  but  in  the  severe  types  it  is  small 
and  rapid.  There  are  anorexia  and  excessive  thirst.  Sometimes 
vomiting  and  attacks  of  hiccough  occur.  In  severe  cases 
there  are  great  prostration  and  wasting ;  the  evacuations  become 
almost  constant  or  involuntary ;  ulcers  form  in  the  mouth  and 
sordes  collect  on  the  teeth ;  delirium  develops,  which  later  in- 
creases to  stupor  and  from  that  tO'  coma. 

The  urine  is  scanty  and  of  high  specific  gravity,  with  an 
excess  of  urea  and  uric  acid  and  a  diminution  of  the  chlo- 
■  rides ;  albumin,  blood,  and  bile  may  be  present  in  it. 


79^  THE    GASTRO-INTESTINAL    CLINIC 

Microscopic  examination  sliows  the  dysenteric  discharge  to 
consist  of  red  and  white  blood  cells,  and  large  round  or  oval 
epithelioid  cells  containing  fat-globules,  vacuoles,  and  putre- 
factive micro-organisms.  Occasionally  the  cercomonas  intes- 
tinalis  is  found  in  large  numbers.  The  specific  germs  which 
have  been  found  are  the  bacillus  pyocyaneus  and  the  bacillus 
of  Shiga. 

Diagnosis. — This  is  rarely  difficult,  except  in  atypical  cases. 
The  fever,  frequent  small  stools  containing  blood  and  mucus, 
with  occasionally  shreds  of  tissue  and  the  other  intestinal  symp- 
toms, are  sufficiently  characteristic. 

Prognosis. — Catarrhal  dysentery  is  often  curable  in  three 
or  four.days,  but,  as  usually  treated,  lasts  on  the  average  in  the 
mild  cases  about  eight  or  nine  days.  The  duration  depends 
largely  upon  the  plan  of  treatment  followed,  as  well  as  upon 
the  grade  of  the  case.  The  severer  cases  often  continue  a 
month,  especially  when  unskillfully  treated  in  the  beginning. 
Recovery  nearly  always  occurs  in  the  temperate  zone,  except 
in  persons  whose  strength  has  been  reduced  by  previous  illness 
or  chronic  disease.  In  infancy  and  extreme  old  age  the  prog- 
nosis is  much  less  favorable.    Occasionally  it  becomes  chronic. 

Treatment. — Mild  cases  of  catarrhal  dysentery  can  often  be 
checked  in  the  very  beginning — when  the  first  mucous  stools 
appear — by  repeated  small  doses  of  castor  oil,  calomel,  or  any 
saline  laxative.  It  was  a  cause  of  surprise  and  no  little  morti- 
fication to  me,  during  my  first  year  or  two  in  practice,  to  find 
that  the  old  women  could  do  more  for  dysentery  by  even  one 
or  two  moderate  doses  of  castor  oil  than  it  was  possible  to  ac- 
complish by  either  ipecac  or  any  combination  of  opium  and 
astringents  upon  which  I  had  been  taught  to  rely.  But  it 
was  not  until  after  many  years  of  experience  with  astringent 
mixtures  and  hard-fought  battles  with  numerous  stubborn 
cases,  which  only  yielded  at  the  end  of  ten  to  fourteen  days  of 
extreme  suffering,  and  the  supervention  in  some  cases  of  com- 
plete exhaustion,  that  I  learned  the  magic  efficacy  of  the  treat- 
ment by  repeated  small  doses  of  one  of  the  saline  laxatives. 


DYSENTERY  79/ 

Either  Epsom  or  Rochelle  salt  is  employed  by  me  as  a  rule,  and 
I  have  the  patient  take  one  or  more  doses,  large  enough  at 
first  to  produce  feculent  stools,  instead  of  the  small  dysen- 
teric evacuations  of  mucus  and  blood,  and  this  is  generally  to 
be  effected  in  the  case  of  adults  by  a  teaspoonful  dissolved  in 
a  goblet  of  moderately  hot  water,  and  repeated  once  or  twice  at 
intervals  of  three  or  four  hours.  In  the  milder  cases  this  slight 
purgation  may  abort  the  attack  completely.  If  not,  as  soon  as 
the  typical  dysenteric  stools,  voided  with  pain  and  tenesmus, 
have  been  thus  changed  to  feculent  ones,  passed  with  little  or  no 
pain,  you  may  direct  the  dose  of  the  saline  to  be  reduced  to  one 
of  lo  to  20  grains,  and  taken  in  half  a  goblet  of  water,  flavored 
if  necessary,  every  three  hours.  If  this  should  act  too  much  as 
a  physic,  the  dose  must  be  reduced,  and  if,  on  the  other  hand, 
there  should  occur  any  tendency  to  a  return  of  the  small  stools 
containing  only  a  few  teaspoonfuls  of  bloody  mucus,  shreds, 
etc.,  with  straining  and  pain,  the  dose  must  be  again  increased. 
Hot  poultices  or  compresses  will  also  promote  the  cure. 

With  this  plan  of  treatment  and  a  diet  of  milk,  or  better, 
milk  with  one-third  limewater,  taken  not  more  than  a  tumbler- 
ful at  a  time,  once  in  three  or  four  hours,  I  have  seen  numerous 
cases  of  catarrhal  dysentery  completely  cured  in  three  days,  in- 
stead of  the  eight,  ten,  or  more  usually  required  when  the  treat- 
ment is  that  by  astringents  and  opium. 

If,  at  the  end  of  three  days  of  such  a  treatment,  the  feculent 
stools  should  not  show  a  tendency  to  cease,  5-  to  lo-grain  doses 
of  bismuth  subnitrate,  given  after  each,  are  usually  all 
that  is  needed  to  stop  them.  If  not,  I  add  i  grain  of  Dover's 
powder  to  each  dose,  and  if  an  examination  shows  any  ulcera- 
tion or  persistent  catarrhal  inflammation  in  the  rectum  or  sig- 
moid flexure,  enemas  of  bismuth,  a  dram  to  the  pint,  or  later, 
if  necessary,  enemas  of  one  of  the  stronger  astringents  men- 
tioned under  the  head  of  the  treatment  of  bacillary  dysentery, 
should  prove  effective.  Special  topical  applications  to  slug- 
gish rectal  ulcers  may  be  necessary  in  some  exceptional  cases, 
■  and  a  very  convenient  and  effective  remedy  for  such  lingering 


798  THE    GASTRO-INTESTINAL    CLINIC 

trouble  in  the  rectum  or  sigmoid  is  a  suppository  containing  3 
fo  5  grains  of  ichthyol,  one  of  which  may  be  inserted  after 
the  morning  stool  and  one  at  bedtime. 

BACILLARY  DYSENTERY 

Definition. — Bacillary  dysentery  is  a  serious  form  of  the 
disease  and  runs  a  more  protracted  course  than  the  others.  It 
is  accompanied  by  necrosis  and  ulceration  of  the  mucosa  of 
the  colon,  and  the  formation  of  croupous  exudate  or  pseudo- 
membrane.  It  occurs  in  epidemics  with  a  mortality-rate  some- 
times as  high  as  45  per  cent.  It  is  especially  liable  to  occur  in 
armies,  asylums,  prisons,  and  the  like.  Bacillary  dysentery  is 
also  known  as  epidemic,  specific,  and  diphtheritic  dysentery. 

Pathology. — In  the  mild  cases  the  characteristic  lesion  is  a 
thin,  grayish-yelloAv  false  membrane,  covering  the  folds  of  the 
colon.  In  the  severe  form,  there  is  a  diphtheritic  infiltration  of 
all  the  coats  of  the  large  intestines,  which  undergo  coagula- 
tion necrosis.  Considerable  sloughing  occurs,  leaving  exten- 
sive ulceration  of  the  bowel.  The  disease  process,  may  be  con- 
fined to  the  rectum  and  the  sigmoid  flexure ;  occasionally,  how- 
ever, it  extends  to  the  ileocecal  valve,  and  even  into  the  ileum. 

.Etiology. — The  specific  cause  of  this  type  of  dysentery  is 
the  bacillus  dy scut cr ice  discovered  by  Shiga^  during  the  Japa- 
nese epidemics.  Flexner  and  Barker  found  the  same  bacillus 
causing  dysentery  in  the  Philippines.  The  bacillus  dysen- 
terise  belongs  to  the  typhocolon  group,  midway  between  the 
bacillus  coli  communis  and  the  bacillus  typhosus.  It  resembles 
closely  the  typhoid  bacillus,  but  Flexner  found  that  it  is  not  in- 
fluenced by  the  blood-serum  of  typhoid  patients,  but  does  re- 
spond to  the  serum  from  dysenteric  cases,  by  which  the  bacillus 
typhosus  remains  uninfluenced.  This  micro-organism  is  a 
slender  rod,  i  to  3  microns  long,  occurs  in  small  groups,  singly 
or  in  pairs,  and  grows  upon  all  the  ordinary  media.  It  is 
stained  by  all  the  common  aniline  dyes,  but  is  not  stained  by 

'  Centralhl.  f.  Bakt.  tc.  Parasitenk,  1898,  xxiv.,  No.  22-24. 


•DYSENTERY  799 

Gram's  method.  It  is  slightly  motile  and  possesses  flagella 
which  surround  its  body. 

Symptoms. — The  symptoms  are  usually  those  of  the  catar- 
rhal form,  but  exhibit  an  unusual  intensity  from  the  onset.  It 
ma)^  begin  with  a  chill  or  a  rapidly  rising  temperature.  There 
are  early  prostration  and  delirium.  The  abdomen  is  tender  and 
may  simulate  typhoid  fever.  The  abdominal  pains  are  very 
severe.  The  stools  usually  contain  more  blood  than  in  the 
catarrhal  form.  Other  elements  in  the  dejecta  are  membra- 
nous shreds,  thin  black  sloughs,  pus,  and  mucus.  The  stools 
are  dark  brown  in  color  and  often  of  very  fetid  odor;  or  at' 
times  may  be  odorless. 

Secondary  Diphtheritic  Dysentery. — This  is  a  name  given 
by  some  authorities  to  a  mild  form  of  bacillary  dysentery.  It 
occurs  as  a  complication  of  many  acute  and  chronic  diseases, 
It  may  be  the  terminal  event  in  chronic  nephritis,  chronic  car- 
diac disease,  pulmonary  tuberculosis,  and  in  various  cachexias, 
as  well  as  in  certain  acute  ailments,  such  as  typhoid  fever  and 
pneumonia.  The  -symptoms  consist  of  three  or  four  loose 
bowel  movements  daily,  containing  a  little  blood  and  mucus. 
Tormina  and  tenesmus  may  be  wholly  absent,  or,  if  present,  be 
very  slight. 

Diagnosis  of  Bacillary  Dysentery. — The  diagnosis  is  posi- 
tively made  by  finding  the  specific  germ  in  the  stools,  and  by 
means  of  the  agglutination  reaction.  The  technique  of  the 
latter  is  identical  with  that  of  the  Widal  test  and  serves  to  dis- 
tinguish dysentery  from  all  other  infections.  Additional  aids 
in  the  recognition  of  this  disease  are  the  intestinal  symptoms, 
the  odor  of  the  stools,  and  the  presence  in  the  latter  of  false 
membranes.  The  occurrence  of  bacillary  dysentery  in  epi- 
demics is  also  of  diagnostic  value. 

Complications  and  Sequels. — Hemorrhage  and  perforation 
may  occur  in  the  same  manner  as  in  typhoid  fever.  Peritonitis 
may  develop  either  through  perforation,  or  by  extension  of  the 
inflammation  from  the  walls  of  the  intestines.  Other  compli- 
cations are  gastro-intestinal  catarrh,  acute  bronchitis,  pleurisy, 


80O  THE    GASTRO-INTESTINAL    CLINIC 

pleuropneumonia,  endocarditis,  pericarditis,  phlebitis,  ascites, 
anasarca,  meningitis,  cerebral  embolism,  ulcer  of  the  cornea, 
^d  nephritis.  Abscess  of  the  liver,  which  is  commonly  held  to 
be  the  most  frequent  of  all  the  complications  of  amoebic  dysen- 
tery, except  when  it  occurs  in  epidemic  form,  is  rare  in  the 
bacillary  type. 

Bacillary  dysentery  has  a  tendency  to  relapse,  one  infection 
increasing  the  patient's  susceptibility  to  another  attack.  It 
may  be  followed  by  a  chronic  dysentery  or  diarrhea,  paralysis, 
rectitis,  and  stricture  of  the  bowel.  A  septic  arthritis  of  the 
larger  joints  may  supervene,  the  so-called  "  rheumatic  dysen- 
tery of  Sydenham." 

Treatment. — First  of  all,  in  the  treatment  of  bacillary  dys- 
entery, absolute  rest  is  imperative.  The  patient  should  be  con- 
fined to  bed  and  the  use  of  a  bed-pan  insisted  upon.  It  is  even 
recommended  that  to  obtain  local  rest,  a  large,  thick,  and  firm 
pad  be  applied  to  the  abdomen  and  retained  there  by  a  broad, 
tight  binder.  The  medicinal  treatment  should  be  begun 
with  a  dose  of  castor  oil  or  a  saline  purge,  which  tends  to 
deplete  the  mucosa.  In  the  later  stages  of  the  bacillary 
form  purgatives  are  harmful.  Ipecacuanha  has  long  been 
considered  almost  specific  in  its  management,  and  is  best  given 
in  large  doses,  though  some  authorities  prefer  small  and  fre- 
quent doses  of  the  drug.  The  following  is  the  classic  method 
of  prescribing  it :  Nourishment  of  every  description  is  with- 
held for  three  or  four  hours.  Then  15  to  25  drops  of  the  tinc- 
ture of  opium  are  administered.  In  from  twenty  to  thirty 
minutes,  when  the  opium  begins  to  take  effect,  from  30  to  60 
grains  of  ipecac  are  administered  in  powdered  form,  stirred 
up  in  one  or  two  ounces  of  water.  The  patient  should  be  kept 
as  quiet  as  possible;  the  slightest  exertion  or  disturbance  may 
bring  on  an  attack  of  vomiting.  If  the  drug  is  vomited  within 
an  hour,  repeat  the  dose  as  soon  as  nausea  subsides.  If  the 
ipecac  is  retained  two  hours  or  more,  sufficient  has  been  ab- 
sorbed to  produce  the  desired  effect.  The  continuance  of  the 
ipecacuanha  will  depend  upon  the  character  of  the  stools.    One 


DYSENTERY  80I 

dose  may  bring  about  a  feculent  stool,  but  failing  improve- 
ment, the  drug  should  be  continued  twice  a  day  in  lo-grain 
doses  for  several  consecutive  days.  After  the  administra- 
tion of  this  drug  no  food  or  drink  is  allowed,  except  the  suck- 
ing of  a  little  ice,  for  at  least  three  hours,  when  small  and  fre- 
quent feedings  may  be  begun.  As  the  dysenteric  patient  may 
also  be  infected  with  malaria,  it  is  well,  in  case  the  ipecac  fails, 
to  give  quinine  in  5-grain  doses  every  six  hours  for  two  days. 
Besides  the  ipecac,  other  drugs  are  often  indicated  in  the  treat- 
ment of  bacillary  dysentery.  Opium  is  the  most  valuable 
means  of  allaying  pain,  restlessness,  or  undue  peristalsis. 
Morphine  is  the  best  form  of  it,  and  should  be  administered 
hypodermically.  A  2-grain  opium  suppository,  or  30  minims 
of  the  deodorized  tincture  by  enema,  may  relieve  the  tenesmus. 
After  the  more  intense  symptoms  have  subsided,  bismuth,  and 
especially  betanapthol  bismuth,  is  a  valuable  preparation.  An- 
ders recommends  the  continued  use  of  Dover's  powder,  bis- 
muth subnitrate,  and  salol.  The  bichloride  of  mercury  in  i-ioo- 
grain  dose,  every  two  hours,  has  given  good  results.  Stengel^ 
recommends  the  employment  of  sulphur.  Weisenberg"  also 
reports  excellent  results  from  the  drinking  of  the  water  of  a 
sulphur  spring  by  the  dysenteric  patients  in  Manila.  Tyson 
advises  the  use  of  iodoform  in  1-2-  to  3-grain  doses  in  capsule 
or  pill. 

In  the  tropics  simaruba  bark,  monsonia  orata,  and  the  as- 
tringent juice  of  the  unripe  guava  fruit  are  popular,  and,  it  is 
claimed,  effective  remedies  which,  however,  are  not  much  em- 
ployed in  the  temperate  zone. 

Opinions  differ  as  to  the  local  treatment  of  acute  dysentery 
by  means  of  enemas.  Some  believe  this  to  be  the  rational 
method,  while  others  condemn  it.  Usually  the  bowel  is  so  ir- 
ritable that  this  mode  of  medication  is  difficult.  To  relieve  the 
irritability,  cocain,  either  in  solution  or  in  suppository, 
or  a  laudanum  enema  is  useful.    The  most  valuable  agents  are 

1  Proc.  Phila.  County  Med.  Soc,  1902. 
^  Phila.  Med.  Jour.,  March  14,  1903. 


802  THE    GASTRO-INTESTINAL    CLINIC 

silver  nitrate  (grn.  ss.  to  f^i),  1-2  to  i  per  cent,  tannic  acid, 
I  to  2  per  cent,  salicylic  acid,  or  mercuric  chloride  solution 
(t-6000).  Lukewarm  injections  of  potassium  permanganate 
solution  (1-4000),  twice  daily,  have  given  good  results  in  the 
hands  of  some  clinicians.  Shiga  has  produced  a  serum  from 
goats  by  means  of  which  he  was  able,  in  an  epidemic  in  Japan, 
to  reduce  the  death-rate  from  34.7  to  9.6  per  cent.  Excellent 
results  have  been  reported  from  the  use  of  this  serum  in  doses 
of  about  20  c.c.  conjointly  with  local  injections  of  germicides. 
The  diet  in  the  acute  initial  stage  should  consist  of  rice 
water,  weak  chicken  broth,  whey,  very  weak  tea,  barley  water, 
or  koumiss.  Later  a  pure  milk  diet  is  indicated.  The  stools 
must  be  watched  to  determine  whether  the  food  is  expelled  un- 
digested, and  if  so  the  diet  must  be  decreased  in  amount,  al- 
tered in  quality,  or  what  is  sometimes  better,  predigested. 

AMCEBIC    DYSENTERY 

Etiology.— This  form  of  dysentery  is  due  to  the  amoeba  coli, 
which  was  discovered  by  Lambl  in  1859.  Kartulis,'  however, 
was  the  first  observer  to  claim  it  to  be  the  specific  cause  of 
tropical  dysentery.  Since  then  this  micro-organism  has  been 
found  constantly  present,  not  only  in  the  stools,  but  also  in  the 
coats  of  the  large  intestine  and  in  the  liver  abscesses  secondary 
to  this  form  of  dysentery.  If  a  small  fleck  of  the  flocculent 
mucus  of  a  dysenteric  stool,  immediately  after  being  passed,  is 
placed  on  a  warm  (100"  F.)  microscope  stage,  the  amoeba  may 
be  recognized.  The  amoeba  coli  is  about  five  times  the  size  of  a 
red  blood  cell ;  it  is  colorless,  or  very  faintly  greenish  in  hue, 
and  consists  of  a  granular  endosarc,  with  a  narrow  zone  of 
clear  colorless  ectosarc.  It  contains  a  nucleus  and  one  or 
more  vacuoles.  When  recently  voided,  it  is  in  constant  char- 
acteristic motion.  This  parasite  is  sometimes  found  in  very 
great  numbers.  Then  again  only  a  few  may  be  present.  The 
number  of  amcebse  present    seems  to  bear  very  little,  if  any, 

'  Massenhafte   Entwickelung  von    Amoeben   in   Dickdarra,    Virchow's 
Archiv,  65,  1875. 


DYSENTERY  803 

relation  to  the  severity  of  the  disease.  If  the  pus  from  a  Hver 
abscess  shows  no  amoebae,  a  gauze  swab  should  be  twisted, 
with  considerable  pressure,  against  the  broken-down  liver 
tissue  forming  the  abscess  wall;  in  this  manner  one  obtains  a 
mass  of  liver  cells  and  leucocytes,  among  which,  in  all  proba- 
bility, the  amcebse  will  be  found.     The  specific  germ  probably 


Fig.  97. — Amoeba  dysenteriie.     (After  Roos.) 

enters  the  body  through  the  drinking  water.     (See  annexed 
illustration  of  the  amcebse.) 

Pathology. — There  is  cedematous  swelling  of  the  intestinal 
wall  and  a  cellular  infiltration  of  the  submucosa.  The  surface 
of  the  mucous  membrane  presents  circumscribed  thickenings 
of  various  size,  in  which  there  are  cavities  filled  with  a  gelat- 
inous mass.  The  openings  to  these  cavities  or  ulcers  are  very 
small  in  comparison  with  the  extent  of  destroyed  tissue  under- 
neath the  mucosa.  The  latter  sloughs  away,  leaving  extensive 
irregular  ulcers;  these  may  be  connected  with  each  other  by 
fistulous  channels  beneath  the  mucosa.  This  ulcerative  process 
usually  involves  only  certain  parts  of  the  colon,  like  the  hepatic 
and  sigmoid  flexures,  but  occasionally  the  entire  large  in- 
testine is  affected.  If  the  disease  is  well  advanced,  healing  may 
be  found  more  or  less  extensive ;  contraction  of  the  scar  tissue 
causes  irregularities  in  the  surface  of  the  mucous  membrane 
and  occasionally  results  in  the  formation  of  strictures.     Mi- 


804  THE    GASTRO-INTESTINAL    CLINIC 

croscopic  examination  of  the  infiltrate  shows  the  absence  of 
pus  and  a  prohferation  of  the  fixed  connective-tissue  cells. 
Amoebse  are  found  in  the  walls,  the  base  of  the  ulcers,  in  the 
lymph  channels,  and  rarely  in  the  blood-vessels. 

Symptoms. — Amoebic  dysentery  may  begin  gradually  or 
suddenly.  It  usually  comes  on  insidiously  with  a  moderate 
and  painless  diarrhea,  alternating  with  short  periods  of  consti- 
pation. Whether  sudden  or  gradual  in  onset,  there  are  irregu- 
lar periods  of  intermission  (from  one  day  to  three  weeks)  antl 
of  exacerbation  (one  to  ten  days).  There  is  usually  a  slight 
fever,  which  may  be  entirely  absent ;  nausea  and  vomiting  are 
uncommon,  and  abdominal  griping  and  tenesmus  are  present 
only  at  the  beginning.  The  stools  are  at  first  mucous  and 
bloody;  later  they  become  fluid  and  yellowish  gray  in  color, 
containing  mucus  and,  at  times,  blood;  they  vary  in  number 
from  six  to  twelve  in  twenty-four  hours.  Active  amoebae  are 
found  in  the  dejecta. 

This  disease  is  usually  accompanied  by  a  progressive  loss  of 
flesh  and  strength  and  a  marked  ansemia. 

Complications. — Hepatic  abscess  is  the  most  frecjuent  and 
serious  complication.  It  is  liable  to  develop  in  from  four  to 
twelve  weeks.  From  20  to  25  per  cent,  of  amoebic  dysenteries 
cause  liver  abscess.  The  latter  may  be  single  or  multiple ;  the 
single  abscesses  are  usually  situated  in  the  right  lobe  of  the 
liver,  near  its  convexity.  The  multiple  abscesses  are  dissemi- 
nated. They  may  be  the  size  of  a  pigeon's  egg,  or  as  large  as 
a  cocoanut,  or  even  larger.  The  pus  found  in  such  an  abscess 
is  thick,  reddish-brown  or  chocolate-brown  in  color.  Micro- 
scopically it  contains  necrotic  liver  tissue,  pus  cells,  amoebse, 
elastic  tissue,  and  blood. 

The  liver  may  also  be  the  seat  of  circumscribed  necrosis, 
scattered  throughout  the  organ,  caused  by  the  action  of  the 
amceb?e.  Perforation  of  the  intestinal  wall  because  of  ulcera- 
tion may  lead  to  peritonitis;  if  this  occurs  in  the  rectum,  a 
periproctitis  results,  or,  if  in  the  cecum,  a  perityphlitis  occurs. 

Diagnosis. — The  presence  of  the  other  dysenteric  symptoms 


DYSENTERY  805 

above  described,  with  the  amoeba  coli  in  the  stools,  estabHshes 
the  diagnosis. 

Prognosis. — Favorable  cases  of  amoebic  dysenter}^  last  from 
six  to  twelve  weeks.  The  mortality  is  much  higher  than  in  the 
catarrhal  form.  In  some  epidemics  the  death  rate  may  reach 
70  to  80  per  cent. ;  in  sporadic  cases,  the  rate  is  much  lower, 
averaging  about  5  per  cent.  This  disease  shows  a  tendency  to 
relapse,  and  the  convalescence  is  prolonged  because  of  the 
anfemia  and  debility. 

Treatment. — In  severe  cases  the  patient  should  be  kept  at 
rest  in  bed,  but  in  the  milder  forms  may  be  allowed  to  be  up 
and  about  for  a  short  time  daily  and  directed  to  take  slight  ex- 
ercise in  the  open  air.  The  food  must  be  highly  nutritious  and 
easily  assimilable.  The  medicinal  treatment  should  include,  as 
a  rule,  that  already  described  above  as  applicable  to  the  treat- 
ment of  bacillary  dysenter)^  The  most  satisfactory  single 
remedy,  however,  for  this  variety  of  dysentery  has  been  found 
to  be  rectal  injections  of  a  warm  solution  of  quinine  (1  to 
5000,  I  to  2500,  or  I  to  1000). 

CHRONIC  DYSENTERY 

Chronic  dysentery  usually  succeeds  acute  dysentery,  al- 
though it  may  be  a  subacute  or  chronic  process  from  the  be- 
ginning in  amoebic  cases.  The  amoeba  coli  is  the  cause  of 
most  cases  of  chronic  tropical  dysentery. 

Pathology. — The  lesions  found  are  similar  to  those  described 
in  the  other  varieties  of  dysentery.  Ulceration  may  be  present 
or  absent.  Some  of  the  ulcers  show  no  signs  of  healing,  while, 
in  others,  a  process  of  repair  is  going  on.  In  some  areas  the 
healing  is  completed  and  the  mucosa  presents  a  rough,  irregu- 
lar, puckered  appearance.  All  of  the  coats  of  the  bowels  are 
thickened.  The  mucous  membrane  presents  black  or  slate- 
gray  patches,  due  to  the  extravasation  and  disintegration  of 
the  blood.  The  glandular  elements  may  be  the  seat  of  cystic 
degeneration. 

"Symptoms. — The  symptoms  are  not  especially  characteristic. 


8o6  THE    GASTRO-IXTESTINAL    CLINIC 

The  stools  vary  from  four  to  twelve  in  twenty-four  hours,  may 
be  fluid,  frothy,  or  semifluid,  yellowish  or  brown ;  occasionally 
the}'-  contain  mucus,  undigested  food,  rarely  blood,  pus,  or  ne- 
crotic shreds.  Constipation  may  alternate  with  diarrhea,  in 
which  case  the  bowel  movements  are  apt  to  be  scybalous,  and 
each  separate  fecal  mass  is  covered  with  tenacious  mucus.  The 
amoeba  coli  is  constantly  present  in  the  amoebic  form,  but,  in 
the  bacillary  form,  the  Shiga  bacillus  disappears  as  the  dis- 
ease becomes  chronic,  particularly  when  there  is  marked  ul- 
ceration. 

Acute  exacerbations  are  not  tincommon.  Tormina  and  te- 
nesmus are  rarely  present,  except  during  the  exacerbations. 
Pressure  in  the  left  iliac  fossa  over  the  sigmoid  flexure,  and 
sometimes  in  the  right  iliac  fossa  over  the  cecum,  elicits  pain ; 
the  sigmoid  flexure  may  be  felt  to  be  indurated,  enlarged,  and 
tender.  Flatulence  may  cause  considerable  distress.  The 
tongue  is  red  and  glazed  or  dry  and  fissured.  The  appetite  is 
impaired  and  digestion  poor.  Anaemia  is  usually  present,  and 
the  emaciation  may  be  extreme. 

Complications. — The  complications  are  those  of  the  acute 
form.  Because  of  extreme  debility  the  patient  is  very  subject 
to  intercurrent  disease,  such  as  pneumonia,  cardiac  failure,  or 
tuberculosis.  It  is  claimed  that  ulceration  of  the  cornea  may 
be  a  complication.  Persistent  indigestion  and  irritability  of  the 
bowels  may  follow  chronic  dysentery. 

Diagnosis. — The  history  of  an  antecedent  acute  attack,  the 
occurrence  of  exacerbations,  together  with  the  characteristic 
dysenteric  stools,  serve  to  distinguish  this  disease  from  chronic 
diarrhea.  It  is  differentiated  from  tuberculous  ulceration  by 
the  absence  of  a  family  history  of  tul^erculosis  or  of  tubercu- 
lous disease  in  other  parts  of  the  body. 

Prognosis.^ — This  depends  upon  the  severity  of  the  symp- 
toms, the-  duration  of  the  disease,  and  the  extent  to  which  the 
health  of  the  patient  has  been  compromised.  It  may  be  pro- 
longed over  a  period  of  months,  or  even  years. 

Treatment. — Internal    medication    is    considered    by    many 


DYSENTERY  807 

writers  as  of  little  value  in  chronic  dysentery,  but  benefit  has 
been  reported  from  the  use  of  the  following:  5  to  10  grns.  of 
zinc  oxide,  three  times  a  day;  salol,  alone  or  in  combination 
with  bismuth;  sulphur  in  lo-grn.  capsules,  three  or  four  times 
a  da}^  with  sufficient  opium  to  overcome  the  laxative  effect. 
Mercuric  chloride  (corrosive  sublimate)  in  i-ioo  grn.  doses 
every  two  hours  has  been  employed  with  marked  success  in 
this  disease.  In  my  earlier  practice  I  encountered  a  number 
of  previously  stubborn  cases  in  which  it  proved  markedly  suc- 
cessful with  the  help  of  an  exclusive  milk  diet.  (See  Phila- 
delphia Medical  Times  of  1879.)  One  such  case  which  had 
yielded  to  the  treatment,  but  relapsed  several  times  in  conse- 
quence of  the  fact  that  the  patient,  who  was  a  sailor,  could  not, 
when  on  a  cruise,  follow  the  diet  prescribed,  was  finally  cured 
completely  by  a  toxic  dose  of  litharge — about  a  teaspoonful — 
which  the  patient  took  on  the  advice  of  some  lay  friend.  He 
suffered  for  several  days  afterward  from  violent  lead  colic  and 
came  near  dying,  but,  after  convalescing  from  the  effects  of  the 
remedy,  remained  afterward  free  of  dysentery. 

The  local  treatment  is  of  special  importance  in  the  manage- 
ment of  chronic  dysentery.  The  remedy  of  greatest  value  is 
silver  nitrate.  A  solution  of  this  preparation  is  made  by  dis- 
solving 10  to  20  grains  in  a  pint  of  water;  of  this  one-half  to 
one  pint  may  be  carefully  injected  every  other  day,  and  some 
bold  authorities  advise  the  use  of  three  to  four  pints  in  the 
same  way.  Before  administering  the  silver  enema,  the  bowel 
should  be  irrigated  with  a  weak  solution  of  sodium  bicarbo- 
nate, and  care  should  be  exercised  that  nearly  all  the  former 
solution  escapes  again.  The  days  on  which  no  silver  enema  is 
given,  the  patient  should  receive  rectal  injections  of  antiseptic 
solutions,  such  as  mercuric  chloride  (i  to  6000)  or  i  to  2  per 
cent,  salicylic  acid.  Other  preparations  useful  in  injections 
are  creolin,  copper  sulphate,  zinc  sulphate,  alum,  iodide,  car- 
bolic acid,  and  chlorine  water.  During  acute  exacerbations 
these  injections  must  not  be  given,  but  the  patient  is  to  be 
treated  as  in  acute  dysentery. 


8o8  THE    GASTRO-INTESTINAL    CLINIC 

The  dietary  should  follow  the  same  lines  as  in  acute  dysen- 
tery, but  be  more  nourishing.     Milk  is  usually  the  best  food. 

Changes  of  climate  and  sea  voyages  are  often  beneficial. 

As  a  last  resort  in  chronic  and  apparently  hopeless  cases, 
operative  treatment  may  be  instituted.  The  object  is  to  put 
the  colon  at  rest,  and  also  to  facilitate  through-and-through  ir- 
rigation. The  colon  is  brought  up  and  fastened  to  the  edges 
of  an  incision  in  the  right  side  of  the  abdomen,  and  is  irri- 
gated directly  through  this  opening.  This  procedure  has,  in 
some  cases,  cured  chronic  dysentery. 

Note. — Dr.  A.  Ruffer  of  Alexandria,  in  discussing  dysentery  before  the 
i6th  Internat.  Med.  Congress  in  September,  1909,  stated  as  a  result  of  the 
study  of  over  400  cases  annually  among  returning  pilgrims  at  El  Tor, 
Egypt,  that  two  main  typesare  encountered,  theamoebic  and  the  bacillary, 
and  not  infrequently  a  mixed  form.  Only  two  per  cent  gave  a  serum  re- 
action with  the  Shiga-Kruse  bacillus.  The  Flexner  bacillus  and  also  the 
so  called  pseudo-dysenteric  bacilli  A  and  D  were  sometimes  found.  To 
another  entirely  distinct  the  name  Tor  bacillus  was  given.  At  least  nine 
different  micro-organisms  including  six  bacilli  were  recognized  as  causes 
of  dysentery  seen  among  the  pilgrims.  In  those  due  to  the  Shiga-Kruse 
bacilli  brilliant  results  were  obtained  from  serotherapy,  while  in  the  Tor 
cases  this  had  no  effect.  Various  others  have  also  reported  good  results 
with  the  anti-dysenteric  serum  in  the  Shiga-Kruse  forms  and  its  useless- 
ness  in  other  forms. 

Professor  Wm.  A.  Edwards  of  Los  Angeles  tells  me  that  he  sees  many 
cases  of  dysentery  including  generally  manageable  ones  of  the  Flexner 
form  as  well  as  some  of  the  Shiga-Kruse  type  which  are  much  more  fatal. 
Among  adults  the  disease  is  apparently  rare  on  the  Pacific  coast.  During 
my  practice  for  a  period  of  over  four  years  in  the  Los  Angeles  region  I 
have  seen  one  case  only  and  that  once  in  consultation.  The  patient  had 
resided  in  Cliina  a  number  of  years  and  since  returning  had  been  under 
Christian  science  till  nearly  dead.     It  was  an  amoebic  case. 


LECTURE  LXXIII 

MEMBRANOUS  CATARRH  OF  THE  INTES- 
TINES (COLICA  MUCOSA,  MYXONEURO- 
SIS INTESTINALIS  MEMBRANACEA) 

This  affection  is  doubtless  rather  more  prevalent  in  the 
United  States  than  in  Europe,  and  was  studied  by  various 
American  writers  before  it  had  attracted  special  attention 
abroad.  The  late  Dr.  J.  M.  Da  Costa  was  probably  the  first  to 
publish  a  full  and  thorough  scientific  paper  concerning  it.^ 
Various  theories  have  been  held  regarding  its  aetiology  and 
pathology,  the  prevailing  view  at  present  being  that  the  abun- 
dant secretion  of  viscid  mucus  which  characterizes  the  affection 
is  due  to  a  disturbance  of  the  innervation  of  the  intestine — es- 
pecially of  the  colon,  where  the  excessive  mucus  is  chiefly 
formed — or,  in  other  words,  that  it  is  a  neurosis. 

There  is  much  to  be  said  in  favor  of  this  explanation  of  it, 
and  von  Noorden,  especially,  has  very  ably  championed  it  in 
his  recent  monograph  on  the  subject,^  the  American  edition  of 
which  was  edited  by  me.  But  it  is  generally  admitted  that  a 
certain  proportion  of  the  cases  presenting  the  symptom  mucous 
colic  are  associated  with  a  true  enteritis. 

While  some  observations  have  apparently  shown  that  in 
certain  cases  of  the  affection  no  catarrhal  inflammation  ex- 
isted, it  does  not  seem  to  me  satisfactorily  demonstrated  that 
there  may  not  be.  in  even  the  cases  classed  as  neurotic,  a  slight 
degree  of  enteritis,  and  I  prefer,  therefore,  not  to  include  this 
lecture  upon  the  subject  among  the  neuroses  of  the  intestines. 
Nevertheless,  it  cannot  be  denied  that  in  most    if  not  all  in- 

'  Am.  Jour.  Med.  Sciences,  October,  1871. 

"^  "  Membranous  Catarrh  of  the  Intestines,"  New  York,  E.  B,  Treat  & 
Co.,  1903. 

809 


8lO  THE    GASTRO-INTESTINAL    CLINIC 

stances,  the  patients  are  hysteric  or  neurasthenic,  and  that  the 
nervous  constitution  is  a  strongly  predisposing  cause.  Von 
Noorden  himself  says :  "  The  scanty  anatomic  material  at  our 
disposal,  therefore,  teaches  us,  on  the  one  hand,  that  colica 
mucosa  may  be  one  of  the  symptoms  of  genuine  enteritis,  and, 
on  the  other  hand,  that  this  affection  may  also  occur  without 
any  essential  anatomic  lesion  of  the  mucous  lining  of  the  in- 
testine, or  even  without  any  anatomic  lesions  whatever." 

Nothnagel  holds  to  the  view  that  there  are  two  distinct 
diseases,  one  a  true  enteritis,  complicated  by  the  discharge  of 
membranes,  etc.,  from  the  bowel,  and  often  by  colic,  and  the 
other  a  strictly  neurotic  affection  in  which  the  latter  symp- 
toms are  independent  of  any  inflammatory  process.  Ewald 
enunciated  the  same  opinion  in  a  recent  noteworthy  paper.^ 
He  calls  the  neurotic  form  of  the  affection  "  Myxoneurosis  In- 
testinalis  Membranacea." 

.ffitiology.  — All  are  agreed  that  nervous  persons  are  most  af- 
flicted with  this  disease,  that  hysteria  and  neurasthenia  are  de- 
cidedly predisposing  conditions.  So,  also,  are  displacements  of 
the  stomach,  colon,  or  kidneys.  Peritoneal  adhesions  and  eye- 
strain, according  to  Morris  of  New  York,  are  other  causes  of 
the  intestinal  neuroses,  including  possibly  mucous  colic." 

Careful  studies  have  been  made  relative  to  associated  gas- 
tric conditions,  but  no  particular  fault  in  the  stomach,  except 
displacements  of  it,  has  been  found  to  be  especially  provoca- 
tive of  colica  mucosa.  It  occurs  with  excessive,  as  well  as  with 
deficient  gastric  motility,  and  with  both  the  extremes  of  gas- 
tric secretion,  but  von  Noorden,  in  seventy-six  cases,  found 
four  only  suffering  from  achylia  gastrica,  while  "  in  the  others 
there  was  comparatively  frequently  a  condition  of  hyper- 
acidity." by  which  he  undoubtedly  means  hyperchlorhydria. 
Ewald  includes  the  climacteric  among  predisposing  conditions. 

Prolonged  constipation,  and  especially  constipation  de- 
pendent upon  a  long-standing  chronic   intestinal  catarrh   of 

■■  Anier.  Med.,  February,  IQ04. 

'  N.  V.  Med.  Record,  December  26,  1903. 


MEMBRANOUS    CATARRH    OF    THE    INTESTINES  8X1 

the  ordinary  form;  though  of  mild  degree,  is  probably  one  of 
the  most  common  causes  of  membranous  catarrh  of  the  in- 
testines. Uric  acid  or  the  uratic  diathesis,  and  especially  such 
results  of  an  imperfect  metabolism  as  the  xanthin  bases,  are 
believed  to  be  capable  also  of  causing  the  disease  now  under 
consideration. 

Symptoms. — Colic  is  usually  given  as  one  of  the  most  promi- 
nent symptoms,  and  this  is  true,  as  a  rule,  of  the  worst  types ; 
but  I  very  often  encounter  cases  in  which  nervous  persons  dis- 
charge much  mucus  from  the  bowel,  including  membranous 
pieces,  shreds,  strings,  etc.,  without  suffering  at  all  from  the 
colicky  pain  described  as  typical  of  the  affection.  The  pieces 
of  membrane  thrown  off  are  of  various  sizes  and  may  be  in 
long  stringy  pieces,  or  perfect  casts  of  portions  of  the  colon. 

The  frequent  passage  of  such  membranes  and  the  abnormali- 
ties in  defecation,  usually  constipation,  constitute  with  the 
marked  nervous  tendency  the  only  constant  distinctive  symp- 
toms of  the  disease. 

In  typical  cases  the  colic  is  a  very  conspicuous  feature,  and 
is  usually  most  marked  when  the  bowel  movements  have  been 
most  deficient.  The  pain  is  often  severe,  and  continues,  as  a 
rule,  until  a  complete  evacuation,  not  only  of  the  feces,  but 
also  of  the  retained  masses  of  mucus,  can  be  obtained.  After 
such  an  evacuation  the  colic  and  all  pain  disappear,  not  to 
return  until  there  has  been  a  re-accumulation  of  the  mucus. 
Patients  thus  afflicted  generally  learn  the  great  importance  of 
keeping  their  bowels  freely  open,  and,  therefore,  try  tO'  avoid 
letting  them  become  confined. 

Though  a  colicky  pain  relieved  by  the  passage  of  a  cjuantity 
of  mucoid  membranes  or  masses  will  be  observed  in  the  se- 
verer cases,  in  the  milder  ones  there  will  be,  instead,  often 
merely  a  dull  discomfort  in  the  bowels  which  increases  toward 
evening  and  disturbs  the  sleep  at  night. 

For  the  rest,  more  or  fewer  of  the  symptoms  constantly  ob- 
served in  hysteria  or  neurasthenia,  as  well  as  those  seen  in 
chronic  indigestion,  will  be  present. 


8l2 


THE   GASTRO-INTESTINAL    CLINIC 


The  most  constant  and  conspicuous  of  these  to  be  noted  are 
constipation  and  intestinal  flatulence,  impaired  sleep,  irritable 
temper,  and  a  dirty  pallor  of  the  skin. 

Diagnosis. — In  most  instances  you-  could  have  no  difficulty 
in  recognizing  a  case  of  membranous  catarrh  of  the  intestines 
by  the  peculiar  stringy  or  membraniform  pieces  of  mucus 
passed  with  or  without  the  admixture  of  feces  and  accom- 
panied usually  by  colicky  pain.  In  case  of  doubt,  a  micro- 
scopic examination  of  such  pieces  would  show  their  mucous 
character  and  differentiate  them  from  skins  or  pulpy  portions 
of  fruit,  etc. 

It  is  important  to  distinguish,  when  possible,  the  cases  in 
which  a  true  colitis  of  sufficient  extent  to  demand  attention  in 
the  treatment  is  complicated  by  the  formation  and  passage 
of  membranes  accompanied  by  colic,  since  for  these  the  diet 
and  therapy  generally  need  to  be  modified.  This  cannot  always 
be  done;  usually,  however,  when  there  exists  a  decided  colitis, 
there  will  be  tenderness  o\"er  the  portions  of  the  bowel  in- 
volved and  more  or  less  discomfort,  or  at  times  even  pain  in 
the  colon  at  some  part  of  every  day,  especially  for  several 
hours  preceding  an  evacuation,  or  when  constipation  is  unre- 
lieved, most  of  the  time.  But  in  a  case  of  membranous  colonic 
catarrh,  in  which  there  is  either  no  true  inflammation  or  only 
a  very  slight  degree  of  it,  not  sufficient  to  interfere  with  the 
success  of  the  treatment  described  below,  there  is  not  likely  to 
be  sensitiveness  to  pressure  or  palpation,  and  an  attack  having 
ended  with  a  free  opening  of  the  bowels  and  the  passage  of 
the  accumulated  membranes  or  masses  of  mucus,  the  patient 
may  feel  well  and  have  no  discomfort  in  the  intestines  for. days 
or  weeks. 

Pathology. — In  those  forms  of  membranous  catarrh  asso- 
ciated with  a  true  enteritis  or  colitis,  a  swelling  or  thickening 
and  serous  infiltration  of  the  mucosa  exist  w^ith  usually  pro- 
liferation of  the  connective  tissue,  as  in  the  ordinary  types  of 
such  chronic  inflammations.  In  the  other  forms  which  by 
many  writers  are  held  to  be  dependent  entirely  upon  a  neu- 


MEMBRANOUS    CATARRH    OF    THE    INTESTINES  813 

rosis,  the  liypersecretion  of  mucus  resulting  from  some  unknown 
disturbance  of  the  innervation,  no  inflammatory  lesion,  as  a 
rule,  can  be  made  out  during  life  by  any  means  at  our  com- 
mand, and  in  a  very  few  well-observed  cases  which  have  after- 
ward come  to  autopsy,  it  is  said  that  no  evidences  of  inflamma- 
tion in  the  mucosa  could  be  demonstrated.  Boas  considers  the 
far  greater  number  of  cases  of  so-called  colica  mucosa,  which 
at  autopsy  showed  definite  lesions  of  enteritis,  as  "  without 
doubt  of  much  greater  importance  than  any  negative,"  while  von 
Xoorden  maintains,  on  the  contrary,  that  even  the  occasional 
observation  of  such  a  clinical  case,  which  reveals  a  perfectly 
normal  condition  of  the  intestinal  mucosa  on  autopsy,  is  far 
more  significant. 

The  mucus  may  be  in  bands,  strings,  pieces  of  membrane  of 
reticulated  structure,  or  in  the  form  of  a  cast  of  the  bowel. 
There  is  no  sufficient  proof  that  it  differs  essentially  from  the 
mucus  in  other  forms  of  enteritis,  except  that  it  is  tougher  and 
more  sticky  in  consistence,  which  is  doubtless  a  result  of  in- 
spissation,  since  constipation  is  nearly  always  present  in  these 
cases,  and  the  mucus  thus  is  longer  retained. 

Ewald,  in  the  paper  already  cited,  describes  as  follows  the 
mucous  masses  which  make  up  much  of  the  stools  which  are 
found  in  both  forms  of  colica  mucosa : 

"  They  are  composed  of  tenacious  mucinous  bodies,  plus 
fibrin  in  small  amount,  nucleo-albumin,  and  globulin.  The 
mucin  can  be  differentiated  from  the  fibrin  by  using  triacid 
stain.  The  histologic  peculiarities  of  these  slime  masses  have 
been  studied  by  Wolf,  Ewald,  Nothnagel,  A.  Schmidt,  West- 
phalen,  and  others.  They  consist  of  a  homogeneous,  somewhat 
opaque  ground  substance  which  is  interspersed  with  cell 
detritus.  This  detritus  is  composed  of  nuclei  which  are  recog- 
nized because  of  their  strong  refractile  properties,  cell-elements, 
epithelial  and  round  cells,  as  well  as  peculiar  shining  flakes 
which  are  thought  to  be  due  to  hyaline  degeneration  or  an 
imbibition  of  soap.  The  epithelial  cells  usually  show  granular 
degeneration,   are   without   demonstrable   nucleus,    vacuolated 


8 14  THE    GASTRO-INTESTINAL    CLINIC 

and  frequently  broken  up.  Besides  these,  there  are  cholesterln 
crystals,  needles  of  the  fatty  acids,  triple  phosphate  crystals, 
particles  of  undigested  food,  bacteria,  and  occasional  red  and 
white  blood  cells.  It  sometimes  happens  that  there  are  sand- 
like concretions  which  resemble  ground  white  pepper  and  are 
easily  mistaken  for  the  seeds  of  strawberries  or  currants,  but 
their  character  can  be  proven  by  the  addition  of  acetic  acid,  in 
which  they  are  soluble." 

Prognosis. — Membranous  catarrh  of  the  intestines  is  rarely 
fatal,  except  indirectly,  when  long  neglected,  but  under  the 
forms  of  treatment  hitherto  generally  in  vogue,  has  proved 
rather  difficult  to  cure  thoroughly.  The  usual  course  has  been 
slow  improvement,  and  when  after  prolonged  treatment  an  ap- 
parent cure  has  resulted,  there  would  be  a  strong  tendency  to 
relapses  from  slight  causes.  Von  Noorden,  however,  w'ho 
treats  the  disease  in  an  original  manner,  as  will  be  described 
below,  reports  a  recoveiy  in  sixty  out  of  seventy-six  cases,  of 
which  thirty-eight  remained  well  a  year  after  the  termination 
of  the  treatment,  and  the  majority  of  the  cured  patients  re- 
mained well  after  many  years. 

Treatment. — Since  von  Noorden  has  been  so  extraordinarily 
successful  in  the  cure  of  colica  mucosa,  1  have  recently  adopted 
his  method  of  treatment  in  the  main,  for  the  neurotic  cases 
not  demonstrably  complicated  by  colitis  or  enteritis,  with  results 
which  are  decidedly  better  than  those  previously  obtained.  I 
will,  therefore,  give  you  a  condensed  account  of  the  method  as 
described  in  his  monograph  already  cited. 

Symptomatic  Treatment. — It  is  obviously  desirable  to  ter- 
minate a  typical  acute  attack  of  mucous  colic  as  soon  as  possible, 
and,  at  the  same  time,  to  relieve  promptly  the  pain  from  which 
the  patieni  suffers.  Both  these  objects  are  best  achieved  by 
putting  tl'.e  patient  to  bed,  applying  hot  applications  such  as 
flaxseed-meal  poultices  or  hot  wet  compresses  over  the  abdo- 
men, the  administration  of  anodynes,  and  flushing  the  colon  to 
remove  the  accumulation  of  mucus.  The  anodyne  should  con- 
sist of  either  morphine  and  atropine  hypodermically,  or  the  same 


MEMBRANOUS    CATARRH    OF    THE    INTESTINES  815 

in  larger  doses  by  suppository.  Von  Noorden  recommends  4 
cgr.  {2-^  grn.)  each  of  ext.  opii  and  ext.  belladonnse  in  sup- 
pository. Such  a  combination,  aided  by  the  hot  apphcations  and 
repeated  in  a  few  hours  if  necessary;  relaxes  the  spasm  and  fa- 
cilitates the  evacuation  of  the  spastically  contracted  bowel,  thus 
giving  prompt  relief  and  cjuickly  ending  the  attack.  In  the  ab- 
sence of  the  narcotic,  the  colon  douche  would  probably  irritate, 
especially  if  any  such  an  excitant  as  soap  or  glycerin  were 
added.  Von  Noorden  includes  salt  in  the  same  category  with 
irritants,  but  most  of  us  have  found  that  when  salt  is  dissolved 
in  water  at  the  temperature  of  the  body,  in  a  strength  of  not 
more  than  a  dram  to  the  quart,  the  result  is  a  more  soothing 
mixture  than  plain  water.  One  to  two  hours  after  the  first 
water  enema,  you  may  inject  half  a  pint  to  a  pint  of  sweet  oil 
or  cotton-seed  oil  to  insure  the  thorough  softening  and  removal 
of  any  remains  of  hardened  and  adherent  mucus. 

Causal  Treat  incut. — Formerly,  the  chief  attention  in  these 
cases  was  g'iven  to  the  treatment  of  the  hysteria  or  neu- 
rasthenia in  the  always  neurotic  patients — generally  young  or 
middle-aged  women — who  suffered  from  this  affection.  Von 
Noorden  believes  that,  while  not  neglecting  this  predisposing 
factor  in  such  cases,  we  should  earnestly  combat  the  constipa- 
tion which  excites  the  attacks. 

Dietetic  treatment  will  accomplish  most.  The  usual  pre- 
scription of  a  bland,  non-irritating  diet,  which  leaves  too  little 
residue  to  overcome  the  constipation  is  condemned,  and  instead 
the  patient  is  required  to  take,  beside  a  large  amount  of  milk 
and  cream  for  the  fat  they  contain,  a  very  coarse  laxative  diet 
including  the  grains,  legumens,  and  the  other  vegetables  which 
have  in  them  much  cellulose;  also  plentifully  of  the  seedy 
fruits  such  as  figs  and  the  1)erries — especially  currants,  goose- 
berries, etc. — just  the  sort  of  diet  which  is  certainly  contra-in- 
dicated in  any  case  in  which  a  decided  enteritis  exists.  Hence 
you  should  be  careful  to  differentiate  your  cases  and  exclude 
from  the  number  treated  by  this  von  Noorden  method  any  in 
which  a  true  colitis  is  a  prominent  feature. 


8l6  THE    GASTRO-INTESTINAL    CLINIC 

In  applying  the  diet  rules  here  prescribed,  it  is  also  of  the 
highest  importance  to  study  the  metabolism  of  each  patient, 
j!nd  vary  accordingly  the  choice  and  quantities  of  the  different 
kinds  of  food  ordered. 

Von  Noorden  considers  the  improvement  of  the  general  nu- 
trition the  fundamental  preliminary  condition  to  be  fulfilled  if 
we  would  effect  a  permanent  cure,  and  finds  that  in  many  of 
the  cases  of  colica  mucosa,  this  is  best  accomplished  by  be- 
ginning with  the  familiar  rest  treatment,  including  systematic 
full  feeding.  And  in  the  other  cases,  as  will  be  seen  from  the 
subjoined  detailed  directions  as  to  diet,  etc.,  he  secures  a  partial 
or  modified  rest  treatment.  He  advises  strongly  that  the  cure 
be  carried  out  in  an  institution  or  somewhere  away  from  the  pa- 
tient's home.  His  failures  have  been  mainly  among  patients 
treated  at  home,  and  we  are  all  familiar  with  the  difficulties 
encountered  in  these  cases  under  such  conditions. 

The  average  duration  of  the  systematic  treatment  with  extra 
full  feeding,  as  here  laid  down  and  carried  out  by  von  Noor- 
den, is  three  to  six  weeks,  or  on  the  average  four  weeks. 
•  While  it  is  impracticable  to  prescribe  any  scheme  of  diet 
which  will  suit  every  case,  even  of  the  same  disease,  and  von 
Noorden  deprecates  any  attempt  to  do  this,  he  submits  the  fol- 
lowing as  a  general  outline  of  the  plan  which  he  has  found 
serviceable  in  many  cases : 

Von  Noorden's  Detailed  Directions  for  the  Average  Case 
of  Membranous  Catarrh  of  the  Intestines. — "  In  the  morning 
in  bed,  at  seven  o'clock. — Three-tenths  of  a  liter  of  milk  and 
cream  (two  parts  of  milk  and  one  part  of  thick  sweet  cream, 
ordinarily  O.  Rademann's  sterilized  Holstein  cream)  ;  then, 
usually,  a  rub  with  moderately  cold  water. 

"  At  eight  o'clock. — One-quarter  of  a  liter  of  Kissingen 
(Racoczy)  or  Homburg  Elisabeth  water. 

"  At  nine  o'clock. — Three-tenths  of  a  liter  of  the  milk-cream 
mixture,  or  of  thin  tea  or  coffee  with  much  cream ;  sometimes, 
too,  cocoa  prepared  with  cream  or  butter  and  sweetened  with 
sugar  of  milk.     In  addition,  50  to  70  grams  (i^  to  2^  oz.) 


MEMBRANOUS    CATARRH    OF    THE    INTESTINES  81/ 

of  coarse  bread  containing  much  cellulose,  and  30  to  50  grams 
(i  to  lyi  oz.)  of  butter. 

"  At  ten-thirty. — If  necessary,  a  massage  of  the  intestine,  or 
hydrotherapeutic  treatments  of  different  kinds ;  sometimes 
electrization  of  the  colon. 

"  At  eleven  o'clock. — Soup  made  from  leguminous  plants 
boiled  with  bacon  or  Westphalia  sausages ;  in  addition, 
Graham  bread  with  plenty  of  butter.  Aho  a  glass  of  break- 
fast wine  or  a  small  glass  of  brandy. 

"  At  one  o'clock. — Some  meat  dish,  as  much  as  w^anted.  In 
addition  vegetables  of  different  kinds,  boiled  or  baked  potato 
with  butter.  Fruit  with  coarse  skins  and  large  seeds,  as  cur- 
rants, gooseberries,  cranberries  boiled,  or  a  pound  of  grapes. 
One-half  a  bottle  of  light  Moselle  wine.  After  eating,  rest  in 
bed  for  an  hour  and  a  half,  with  hot  applications  to  the 
abdomen. 

"  At  four  o'clock. — A  light  lunch  similar  to  the  breakfast 
at  nine  o'clock.  Then  a  walk  of  one  and  one-half  to  two 
hours. 

"  At  seven  o'clock. — Supper  like  the  dinner ;  sometimes,  too, 
junket  or  fruit  soup.  In  addition,  50  to  70  grams  (i^  to  2^ 
oz.)  of  Graham  bread,  with  plenty  of  butter. 

"  At  nine  o'clock. — Three-tenths  of  a  liter  of  the  milk- 
cream  mixture  as  in  the  morning. 

"  On  the  first  and  the  third  day  of  the  treatment,  an  oil 
clyster  is  usually  given  in  the  evening  in  order  to  prevent  all 
disturbances  that  might  possibly  arise.  It  is  rarely  necessary 
to  repeat  this  later  on. 

"  The  average  cjuantity  of  cream  consumed  amounted  in  our 
cases  to  one-half  a  liter  a  day;  this  amount  containing  150 
grams  (4^  oz.)  of  pure  butter-fat  (the  manufacturers  of 
the  sterilized  cream,  mentioned  above,  guarantee  a  percentage 
of  30  per  cent,  of  butter-fat).  The  daily  average  of  butter 
equaled  230  grams  (7^  oz.).  Of  this  quantity  about  two- 
thirds  were  eaten  as  pure  butter  with  bread  and  potato,  or  with 
vegetables  and  fish.    The  rest  was  taken  cooked  with  the  food. 


8l8  THE    GASTRO-INTESTINAL    CLINIC 

"  The  average  quantity  of  Graham  bread  was  200  to  250 
grams  (6^  to  8  oz.).  We  usually  give  the  bread  sold  by  O. 
Rademann  (Frankfurt-am-Main)  under  the  trade-mark 
*  D-K.' 

"  According  to  our  experience,  mild  disturbances  occur 
under  this  regime.  It  is  well  to  prepare  the  patients  for  this 
invadvance.  In  order  to  counteract  these  disturbances,  it  is  a 
good  plan  to  keep  the  patients  in  bed  for  the  first  few  days;  in 
addition,  hot  compresses,  or  possibly  suppositories  of  three- 
fifths  cgr.  (i-io  grn.)  of  extr.  belladonnae,  and  the  oil  clysters 
mentioned  above,  may  be  given  (this  on  the  first  and  third 
days  of  the  treatment).  After  the  first  two  to  four  days,  the 
stools  that  are  evacuated  assume  a  normal  consistency  and  a 
normal  appearance.  As  soon  as  this  occurs  all  the  disturbances 
usually  disappear ;  in  particular,  all  painful  sensations.  Mucus, 
however,  is  passed  for  some  time  longer.  This  mucus,  to  judge 
from  its  appearance,  is  freshly  secreted.  This  demonstrates 
that  the  hyperirritability  of  the  mucus-secreting  apparatus  is  not 
allayed  at  once.  At  the  same  time  the  mucus  no  longer  ac- 
cumulates and  the  quantities  passed  are  very  insignificant.  If 
the  cure  takes  a  normal  course,  the  secretion  of  mucus  does 
not  continue  for  longer  than  a  week.  In  at  least  one-half  of 
the  cases  the  secretion  of  mucus  ceases  at  once,  as  soon  as  soft 
motions  are  evacuated,  and  never  returns  thereafter." 

Comments  on  the  von  Noorden  Method. — It  will  be  ob- 
served that  the  above-described  plan  includes  the  administra- 
tion every  morning  of  one-quarter  of  a  liter  (about  a  goblet- 
ful)  of  one  of  the  natural  chloride-of-sodium  waters,  which 
exert  a  very  slight  laxative  action  on  many  sensitive  patients, 
and  a  curative  influence  on  the  intestinal  mucosa.  In  my  ear- 
lier attempts  to  efifect  cures  in  these  cases,  as  well  as  in  others 
in  which  constipation  was  a  marked  symptom,  by  resorting  to 
a  coarse  laxative,  as  various  German  authors  advise,  I  failed 
often,  and  doubtless  because  the  saline  water  was  omitted.  The 
oil  enemas,  too,  are  most  valuable  adjuvants  in  all  such  cases, 
and.  are  still  more  useful — even  indispensable — in  the  treat- 


MEMBRANOUS    CATARRH    OF    THE    INTESTINES  819 

ment  of  constipation,  associated  with  the  famihar  types  of 
chronic  enteritis  or  cohtis. 

The  fact  that  the  Carlsbad  and  other  alkahne  waters  are 
strictly  contra-indicated  in  the  affection  under  consideration, 
as  well  as  in  all  gastro-intestinal  derangements  accompanying 
or  dependent  upon  nervous  or  depressed  conditions,  is  insisted 
upon  by  most  writers,  and  is  mentioned  also  by  the  author 
above  quoted.  The  latter  insists  further  upon  massage  of 
the  large  intestine,  especially  over  the  sigmoid  flexure,  as  a 
most  valuable  adjunct  in  the  treatment  of  these  cases,  not- 
withstanding that  it  is  generally  contra-indicated  in  spastic 
cases.  His  view  is  that,  with  the  usual  bland  diet,  massage 
does  aggravate  all  forms  of  spastic  constipation,  including  that 
occurring  in  colica  mucosa;  but  when  his  full  laxative  diet  is 
adhered  to,  he  finds  that  massage  agrees  perfectly  well,  and 
promotes  complete  evacuations. 

The  After-Treatment. — When  the  three  to  six  weeks  of 
special  treatment  with  full  or  partial  rest,  massage,  electricity, 
etc.,  and  very  full  feeding  on  an  exceptionally  coarse  laxative 
diet  are  over,  the  after-treatment  is  highly  important.  The 
mechanical  measures,  saline  water,  oil  enemas  (when  the  last 
need  to  be  employed),  are  now  to  be  omitted,  and  the  patient  is 
required  gradually  to  resume  an  ordinary  but  rational  diet 
appropriate  to  his  circumstances  and  place  of  residence. 

It  is  customary  after  most  of  the  special  cures  at  German 
springs  or  bathing  places,  to  send  the  patient  to  some  invigo- 
rating climate  for  a  few  weeks,  but  von  Noorden  cautions 
against  ordering  patients  who  have  pursued  the  above-pre- 
scribed course  for  colica  mucosa  to  either  the  seashore  or  to 
any  high  altitude.  He  does  not  know  why  these  localities  dis- 
agree with  convalescents  from  the  affection  under  considera- 
tion, but  experience  has  taught  him  that  they  do.  He  prefers 
that  such  patients  should  go  to  some  wooded  country  at  a 
moderate  altitude,  and  there  take  frequent  short  walks — not 
overtaxing  their  strength. 

The  educational  process  of  adaptation  to  an  ordinary  diet 


820  THE    GASTRO-IXTESTIXAL    CLINIC 

may  be  finished  in  a  few  weeks,  or  exceptionally,  may  take 
several  months.  If  the  patient  too  soon  goes  back  to  a  less 
bulky  diet  before  the  habit  of  daily  spontaneous  and  sufficient 
bowel  movements  has  been  acquired,  and  especially  if  there  is 
a  return  to  any  objectionable  habits  of  eating,  there  is  likely 
to  be  a  relapse ;  but  once  the  normal  habit  is  fuily  restored,  and 
a  rational  mode  of  living  is  thenceforward  followed,  the  cure 
remains  a  permanent  one. 

Treatment  of  Colica  Mucosa  in  True  Enteritis. — In  those 
membranous  catarrhs  of  the  intestines  which  are  nervous  com- 
plications of  a  well-marked  and  decided  enteritis,  the  coarse 
diet  and  forced  feeding  will  rarely  succeed.  The  diet  will  need 
to  be  blander  and  less  irritating  in  all  cases  in  which  an  in- 
flamed condition  of  the  mucosa  is  a  prominent  feature,  though 
there  are  doubtless  numerous  cases  in  which,  while  there  ex- 
ists a  true  enteritis,  it  is  mild,  recent,  and  a  result  merely  of  the 
irritation  produced  by  retained  masses  of  hardened  feces,  and 
in  these  whatever  diet  or  other  remedies  will  best  overcome  the 
constipation  may  prove  effective  for  the  cure  of  the  entire  symp- 
tom-complex. V\'hen  there  is  a  chronically  inflamed  mucosa  of 
a  stubborn  character,  complicated  by  mucous  colic,  you  wnll 
need  to  rely  upon  the  very  carefully  regulated  diet  advised  for 
chronic  enteritis  in  Lecture  LXVL,  and  combat  the  constipa- 
tion or  diarrhea  by  the  therapeutic  measures  recommended  in 
the  lectures  upon  those  subjects.  Nearly  always  there  will  be 
constipation,  and  the  most  successful  single  remed}^  for  it  will 
usually  be  olive,  linseed,  or  cotton-seed  oil,  injected  at  bedtime 
in  doses  of  one  to  eight  ounces  and  retained  till  morning. 
When  more  decided  laxative  drugs  are  needed,  cascara  sa- 
grada,  sulphur,  senna,  dandelion,  or  tamarinds  in  the  smallest 
doses  that  will  empty  the  lower  bowel  every  day  without  lique- 
fying the  stools  will  succeed  best.  A  complete  or  partial  rest 
cure  will  prove  the  most  effectual  remedy  for  the  neurotic 
symptoms,  including  the  excessive  secretion  of  mucus  and  ac- 
companying pain,  and  should  be  supplemented  by  electricity — 
especially  general  faradization  or  some  of  the  static  modalities 


MEMBRANOUS    CATARRH    OF    THE    INTESTINES  821 

for  their  systemic  effect,  and  large  doses  of  galvanism  for 
their  local  alterative  effect  upon  the  diseased  intestinal  mucosa 
as  described  in  Lecture  LXVI.  (See  also  Lectures  XXV., 
XXVL,  and  XXVIL)  Massage  of  the  body  generally  is  in- 
dispensable as  passive  exercise  for  the  patients  who  are  in  bed, 
but  in  the  presence  of  spastic  complications,  such  as  are  almost 
invariably  associated  with  colica  mucosa,  there  should  be  no 
deep  kneading  or  other  irritating  procedures  over  the  abdomen. 
Light  stroking  or  surface  friction  will  be  all  the  manipulations 
which  can  then  exert  a  favorable  action  in  that  region. 

In  this  connection  it  should  be  again  emphasized  as  strongly 
as  possible  that  all  neurasthenic  patients,  including  those  suf- 
fering from,  colica  mucosa,  whether  with  or  without  a  pro- 
nounced enteritis,  need  to  have  rest,  partial  or  complete,  plenty 
of  sleep,  and  at  least  an  adequate  supply  of  nourishing  food  to 
maintain  nutrition  at  its  proper  level. 


LECTURE  LXXIV 

EXCESSIVE   ERUCTATIONS  AND   GASTRO- 
INTESTINAL FLATULENCY  IN  GENERAL 

Flatulency,  or  the  eructation  of  gases  from  the  stomach,  is 
the  most  common  of  all  gastric  symptoms  in  the  various  con- 
ditions usually  grouped  under  the  vague  term,  indigestion  or 
dyspepsia.  And  those  who  have  made  a  special  study  of  the 
numerous  diseases  of  the  digestive  system,  from  the  standpoint 
of  aetiology  and  pathology,  should  be  prepared  to  djscuss  them 
from  the  clinical  side  as  well.  Such  an  important  and  obtrusive 
symptom  as  flatulency  needs  to  be  elucidated  and  traced  to  its 
possible  causes  in  language  easily  intelligible  to  every  practi- 
tioner of  medicine.  Gases  eructated  from  the  stomach  most 
often  result  from  fermentation  or  putrefaction  somewhere  in 
the  alimentary  tract.  The  small  quantities  that  may  be  swal- 
lowed ordinarily,  and  the  little  carbonic  dioxide  taken  some- 
times with  effervescent  drinks  or  disengaged  from  the  carbon- 
ates, are  not  important;  and  the  rare  cases  generally  classed 
under  the  head  of  nervous  eructations  are  only  the  exceptions 
which  prove  the  rule. 

In  thirty-two  years  of  practice  I  have  seen  a  very  few  cases 
only  in  which  there  were  excessive  eructations  of  apparently 
swallowed  air,  and  yet  in  that  time  thousands  of  cases  of  di- 
gestive disorders  characterized  by  much  flatulency  have  been 
under  my  observation.  Even  a  cursory  study  of  these  has 
been  very  interesting.  Full  detailed  reports  and  an  exhaustive 
analysis  of  even  the  more  noteworthy  of  them  would  require 
more  space  than  could  be  spared  here ;  but  an  attempt  has  been 
made  to  classify  them  according  to  their  causes,  relations,  and 
complications.  They  include  cases  of  (i)  fermentation  of 
sugar  and  starch  due  either  to  hyperchlorhydria  or  acid  gastric. 

822 


EXCESSIVE    ERUCTATIONS  823 

catarrh  (gastritis  sthenica),  and  complicated  nearly  always 
with  more  or  less  chronic  intestinal  catarrh;  (2)  chronic 
asthenic  catarrh  of  the  stomach  (gastritis  asthenica)  ;  (3)  mus- 
cular atony  of  the  stomach  (myasthenia  gastrica),  with  or 
without  dilatation  or  prolapse  (gastroptosis),  but  always  with 
delayed  emptying  and  resulting  stagnation  of  the  stomach  con- 
tents; (4)  pyloric  obstruction,  with  stagnation  or  retention  re- 
sulting from  one  of  numerous  obstructive  causes,  such  as 
tumors,  scars  of  ulcers,  stenosing  gastritis,  adhesions  to  ad- 
jacent organs,  spasm  of  the  pylorus  in  severe  hyperchlorhydria, 
or  the  pressure  of  a  prolapsed  right  kidney  upon  the  duo- 
denum; (5)  nervous  dyspepsia  (neurasthenia  gastrica);  (6) 
intestinal  indigestion;  (7)  chronic  intestinal  catarrh  (enteritis 
chronica)  without  gastritis;  (8)  chronic  catarrh  of  the  ap- 
pendix vermiformis  (appendicitis  catarrhalis  chronica),  with 
usually  also  some  involvement  of  other  portions  of  the  intes- 
tines in  the  same  process;  (9)  chronic  constipation  from  ob- 
struction or  other  cause,  apart  from  the  above-named  affec- 
tions; and  (10)  fermentation  in  the  stomach,  dependent  upon 
swallowing  mucus  and  bacteria  having  their  origin  in  the  nose, 
naso-pharynx,  and  mouth,  including  carious  teeth. 

Very  exceptionally,  also,  sufficient  air  may  be  swallowed  to 
produce  excessive  eructations,  but  I  have  not  for  a  number  of 
years  encountered  a  single  case  in  which  such  a  cause  of  eruc- 
tations was  to  be  suspected,  or  in  which  some  more  tangible 
cause  could  not  be  discovered. 

There  are  probably  still  other  causes  of  gaseous  accumula- 
tions in  the  stomach  which  do  not  now  occur  tO'  me ;  but,  with 
two  or  three  possible  exceptions,  I  have  never  met  with  any 
cases  of  eructations  which  could  not  be  accounted  for  as  at- 
tributable to  some  one  of  the  conditions  above  mentioned.  I 
have  not  yet  been  able  to  convince  myself  that  large  quantities 
of  gases  are  secreted  directly  by  the  cells  of  the  stomach,  as 
has  been  claimed  by  some  authors. 

Belched  Gas  often  from  the  Intestines. — It  is  quite  demon- 
st-able,  however,  that  the  gases  so  copiously  produced  by  fer- 


824  THE    G.ASTRO-INTESTINAL    CLINIC 

mentation  and  putrefaction  in  the  intestines  of  many  dyspep- 
tics easily  invade  the  stomach  through  the  pylorus.  This  may 
take  place  at  any  time  when  the  pylorus  is  relaxed,  but  es- 
pecially during  digestion,  while  the  chym.e  is  passing  into  the 
duodenum.  With  the  highly  distended  condition  of  the  intes- 
tines in  these  patients,  the  pressure  is  great  in  every  direction, 
and  manifestly  the  pylorus  must  often  be  the  point  of  least  re- 
sistance, especially  when  the  gut  below  is  obstructed  by  ac- 
cumulations of  feces  or  by  spasmodic  contractions  of  its  cir- 
cular muscle.  ]\Iost  of  the  causes  of  flatulency  given  in  the 
above  classification  are  too  obvious  to  require  discussion.  As 
to  three  of  them,  however,  Xos.  i,  8,  and  lo,  a  few  words  may 
be  in  place. 

Hyperchlorhydria,  the  most  frequent  cause  of  indigestion, 
according  to  Einhorn's  view — which  my  experience  fully  con- 
firms— greatly  increases  the  fermentation  of  farinaceous  foods 
in  the  stomach,  besides  being  one  of  the  most  potent  factors  in 
the  production  of  intestinal  derangements,  especially  gas 
formation. 

Chronic  Appendicitis  as  a  Source  of  Flatulency. — Catarrh 
of  the  appendix,  with  more  or  less  occlusion  of  its  open- 
ing, constantly  breeds  and  sends  out  into  the  cecum,  from  time 
to  time,  colonies  of  highly  virulent  colon  bacilli  as  described  by 
A.  O.  J.  Kelly.^  As  a  result,  the  colon  is  kept  constantly  or  inter- 
mittently infected,  and  even  after  appropriate  measures,  such 
as  abdominal  massage  and  antiseptic  colon  douches,  have 
cured  the  catarrhal  process  in  the  bowel,  there  is  reinfection 
from  the  persisting  catarrh  in  the  appendix,  and  this  probably 
often  involves  the  small  intestine.  The  virulent  bacteria  es- 
caping frequently  from  the  chronically  diseased  appendix  would 
greatly  increase  fermentation  and  putrefaction  in  the  intestinal 
contents,  and,  as  explained  above,  the  gaseous  accumulations 
there  may,  at  times,  find  a  vent  in  the  upward  direction  through 
the  stomach. 

One  evidence  that  in  cases  of  copious  belching  the  gas  may 
1  Phila.  Med.  Jour.,  November  ii,  i8,  and  25,  1899. 


EXCESSIVE    ERUCTATIONS  825 

not  come  from  the  stomach  but  from  the  intestines,  is  an  ob- 
servation often  made  by  me.  In  washing  out  the  stomach  of 
a  catarrhal  patient  afflicted  with  excessive  eructations,  it  would 
be  noted  that  after  completely  emptying  the  viscus  of  all  food 
remains  and  mucus,  there  would  develop,  coincidently  with 
the  opening  of  the  pylorus  to  permit  the  escape  of  the  portion 
of  wash  water  retained,  a  spell  of  active  and  profuse  belching. 
The  stomach  having  been  previously  completely  emptied,  the 
gas  brought  up  could  only  have  come  from  the  bowel  through 
the  pylorus  when  it  opened  for  the  escape  of  the  wash  water. 

Infection  of  the  Alimentary  Tract  from  the  Mouth,  Nose, 
and  Throat. — In  catarrh  of  the  upper  air  passages,  or  in  any 
part  of  the  oral  cavity,  myriads  of  germs,  as  well  as  mucus, 
are  swallowed  with  the  saliva  frecjuently,  and  always  washed 
down  copiously  by  the  food  and  drink.  In  the  case  of  disease 
in  or  about  the  roots  of  the  teeth,  and  especially  when  there  are 
neglected  dental  cavities,  the  germs  are  liable  to  become  very 
virulent  as  well  as  abundant.  The  swallowed  mucus,  once  in- 
fected, is  as  good  a  culture  medium  as  that  produced  in  situ, 
and  is  not  easily  extruded  from  even  a  healthy  stomach. 
Hunter^  has  shown  that  diseased  mouths  may  produce  a  septic 
form  of  gastritis  with  serious  secondary  effects,  going  on  even 
to  pernicious  anaemia  in  some  cases,  and  I  have  recently  seen  a 
case  in  which  purulent  conditions  around  the  teeth,  long  neg- 
lected, coexisted  with  gastric  atrophy  which  had  probably  re- 
sulted from  such  a  gastritis. 

Reflex  Causes  of  Flatulency. — Robert  T.  Morris,  in  a  very 
suggestive  paper  on  Intestinal  Fermentation  as  it  Interests  the 
Surgeon,^  refers  to  the  role  played  by  the  displacements  of  the 
different  abdominal  viscera,  and  by  adhesions  between  the  lat- 
ter and  adjacent  structures  in  the  production  of  neuroses  of 
the  digestive  system,  including  nervous  dyspepsia,  mucous 
colic,  flatulent  conditions,  etc.  Furthermore,  he  emphasizes 
anew  his  former  observation  that  certain  normal  involution 

■■  Afed.  Press  and  Circular,  April  3,  1901. 
^  Loc.  cit. 


826 


THE    GASTRO-INTESTINAL    CLINIC 


changes  in  the  appendix  vermiformis,  which  result  in  the  re- 
placement of  the  lymphoid  and  mucous  layers  with  connective 
tissue,  cause  irritation  of  the  terminal  nerve  filaments   to  such 


Pneumogastric 

left 


Ganglion   - 


Pneumogastric 
right 

Coronary  artery 
Coronary  vein 

Ganglion 

Hepatic  artery 

Gastro-epiploic 
artery 


Ganglion 
Gastro-epiploic   •_ 

vein  ._.j^ 


JvomHartnidiiu  dnd  Cune'o. 


Fig.  98. — The  nerves,  blood  vessels,  and  lymphatics  of  the  stomach. 
(By  permission  of  Dr.  W.  J.  Mayo.) 

an  extent  as  to  set  up  a  train  of  symptoms  generally  classified 
as  intestinal  fermentation. 

Morris  adds  also  a  strong  indorsement  of  Dr.  George  M. 
Gould's  view  regarding  the  importance  of  ocular  defects  as  a 
cause  of  these  neuroses,  testifying  that  "  a  very  large  group  of 
cases  of  intestinal  fermentation  is  dependent  upon  eye-strain." 
He  states  further  on  this  head :  "  The  ones  that  I  see  are  sent 
to  the  office  most  often    with  the  request  to  have  the  appendix 


EXCESSIVE    ERUCTATIONS  82/ 

examined  because  the  distention  of  the  cecum  is  apt  to  cause 
more  pain  than  distention  of  other  parts  of  the  bowel,  and  at- 
tention is  attracted  to  this  region.  If  there  are  external  evi- 
dences of  eye-strain,  these  cases  are  referred  to  the  ophthal- 
mologist along  with  my  cases  of  '  nervous  dyspepsia  '  and  '  gas- 
tric neuralgia,'  and  some  of  the  most  brilliant  results  that  I 
have  observed  in  any  kind  of  medical  practice  have  come  out 
of  the  treatment  that  was  instituted." 

The  exceeding  richness  of  the  nerve  supply  of  the  storhach 
is  shown  clearly  by  the  accompanying  illustration,  Fig.  98. 
The  numerous  branches  of  the  vagi  and  of  the  ganglionic 
nervous  system  ramify  to  every  part  of  the  viscus.  No  wonder 
it  is  so  often  disturbed  reflexly,  and  so  frequently,  on  the  other 
hand,  a  cause  of  reflex  derangements  in  other  organs ! 

The  Treatment. — ^The  cause  of  the  jflatulency  must,  of 
course,  first  be  sought  for,  and  the  therapeutic  measures  then 
be  directed  to  the  underlying  pathologic  state. 

In  fermentative  conditions  with  chronic  gastric  catarrh,  the 
diseased  process  needs  to  be  combated  persistently  by  lavage, 
diet,  massage  (in  the  asthenic  cases),  and  often  hydriatic  pro- 
cedures, as  well  as  by  HCl  and  bitter  tonics  for  deficient,  and 
alkalies  and  sedatives  for  excessive,  gastric  secretion,  aided  by 
all  the  practicable  roborant  measures,  including  a  proper  alter- 
nation of  rest  and  exercise,  and  especially  by  those  recreations 
that  will  keep  the  patients  as  much  as  possible  out  in  the  open 
air  without  unduly  taxing  their  strength.  The  intragastric 
spray  may  be  employed  instead  of  lavage  when  the  latter  fails. 

Intragastric  electricity  may  be  made  very  helpful  in  chronic 
gastric  catarrh,  and  in  deficient  motor  power  of  the  gastric 
muscles ;  therefore,  of  course,  in  all  the  fermentative  condi- 
tions resulting  therefrom. 

-  Antiseptic  drugs  have  often  proved  disappointing  in  my 
hands,  especially  when  administered  by  way  of  the  mouth  with 
the  idea  of  controlling  fermentation  by  a  direct  action.  I 
have  seen  great  good  result  from  even  small  doses  of  HCl — 
2  to  10  drops  of  the  officinal  dilute  acid  in  water  after  meals — 


828  THE    GASTRO-INTESTINAL    CLINIC 

in  cases  of  asthenic  gastric  catarrh  with  a  deficient  gastric  juice, 
the  secretion  of  HCl  increasing,  and  the  fermentation  and  flat- 
ulency being  often  lessened  or  stopped,  but  this  gain  has  seemed 
to  result  mainly  from  a  restorative  action  upon  the  gastric 
glands.  Furthermore,  I  have  seen  in  like  cases,  as  well  as  in 
others  with  fermentation  dependent  merely  upon  diminished 
secretion  of  HCl,  marked  improvement  gradually  result  from 
one  to  two  drops  of  carbolic  acid  or  creosote,  or  even  smaller 
doses,  the  improvement  coinciding  with  a  gain  in  the  amount 
and  quality  of  the  gastric  juice.  In  both  the  usual  forms  of 
gastric  catarrh — whether  the  HCl  be  increased  or  diminished 
— bismuth,  in  doses  of  5  to  50  grains  after  meals,  has  often 
effected  brilliant  results,  especially  in  the  higher  range  of  doses 
when  combined  with  alkalies,  a  milk  diet,  and  absolute  rest,  in 
cases  of  hyperchlorhydria  with  ulcer,  accompanied  by  much 
fermentation  of  starch  foods ;  but  here  the  good  result  doubtless 
comes  more  from  its  mechanical,  soothing  and  absorptive  effect 
than  from  its  antiseptic  action.  Evidence  is  accumulating,  also, 
as  to  the  efficacy  of  magnesium  salicylate  and  bismuth  sali- 
cylate, the  former  when  constipation  and  the.  latter  when  diar- 
rhea accompanies  and  complicates  the  flatulence;  also  some 
of  the  newer  combinations  of  bismuth,  particularly  betanaph- 
tol-bismuth  (orphol)  and  tribromphenol-bismuth  (xeroform). 

In  cases  following  operations  in  the  abdomen,  and  in  all 
others  in  which  there  is  reason  to  suspect  peritoneal  adhesions, 
surgical  aid  may  be  required ;  so  also  when  there  are  dis- 
placements which  have  not  yielded  to  other  suitable  treatment. 
As  in  all  gastro-intestinal  cases,  you  should  carefully  see  to  it 
that  any  ocular  faults  have  been  properly  corrected. 

The  diet  appropriate  to  chronic  gastro-intestinal  catarrhs 
and  the  fermentation  dependent  upon  them  I  have  discussed  at 
length  in  the  lectures  devoted  to  the  subject  of  diet  in  general. 
It  is  unnecessary  to  say  more  here  than  that  it  is  not  safe  to  at- 
tempt to  follow  strictly  any  general  rules,  since  there  are  so 
many  exceptions.  Every  case  must  be  studied  by  itself.  I 
might  venture  the  statement,  however,  that  in  the  true  catar- 


EXCESSIVE    ERUCTATIONS  829 

rhal  cases  much  restriction  is  usually  necessary,  especially  as 
to  the  carbohydrates,  while  in  nervous  dyspepsia  patients  often 
eat  too  little. 

It  is  most  unscientific  and  often  very  harmful  to  attack  the 
flatulence  symptomatically  by  means  of  irritant  antiseptics 
which  w^ould  aggravate  an  unsuspected  hyperchlorhydria,  and 
perhaps  bring  on  a  fatal  gastric  or  duodenal  ulcer.  And  it 
would  be  equally  disastrous  to  treat  a  debilitated,  underfed 
neurasthenic,  suffering  from  nervous  dyspepsia,  by  low  diet 
and  stomach  washing. 

^Vhen  the  fermentation  and  eructation  do  not  depend  upon 
catarrhal  inflammation  in  either  the  stomach  or  small  intes- 
tine there  is  usually  gastric  atony  or  dilatation,  the  treatment 
for  which  must  be  carried  out  as  described  in  the  lecture  de- 
voted to  that  subject,  and  at  the  same  time  lavage  with  anti- 
septic solutions  as  advised  for  asthenic  gastric  catarrh  may 
often  be  practiced  with  advantage  every  day,  or  every  other 
day,  to  cleanse  away  fermenting  food  remains.  The  diet 
should,  for  a  few  weeks  at  least,  contain  as  little  of  the  more 
fermentative  carbohydrates  as  possible. 

In  the  cases  of  nervous  eructation,  the  treatment,  in  addition 
to  electricity  locally,  should  be  that  appropriate  to  the  neuras- 
thenia or  hysteria  upon  which  the  affection  depends. 

Intragastric  applications  of  the  induced  electric  current 
(faradism),  in  connection  with  cold  water  locally,  regulated 
physical  exercise  in  the  open  air,  abundant  sleep,  and  all  the 
other  measures  required  for  neurasthenia,  will  rarely  fail  in 
these  cases,  when  the  eructations  do  not  result  from  some  real 
lesion,  but  you  should  always  examine  closely  into  the  condition 
of  the  intestinal  mucosa,  w^here  will  frequently  be  found  a 
catarrhal  inflammation  which  has  caused  both  the  excessive 
upward  rush  of  gas    and  the  associated  so-called  neurosis. 

In  the  section  on  meteorism,  etc.,  under  the  head  of  Intestinal 
Neuroses,  in  Lecture  LXXVIIL,  I  have  discussed  with  suf- 
ficient fullness  the  subject  of  excessive  flatulency  in  the  in- 
testines in  all  its  forms,  whether  of  nervous  or  other  origin. 


LECTURE  LXXV 

GASTRIC    NEUROSES,    SECRETORY   AND 
SENSORY 

Most  of  the  gastric  affections  having  no  known  anatomic 
basis  are  assumed  to  be  of  nervous  origin,  and  as  to  a  certain 
proportion  of  them,  this  is  probably  correct.  I  shall,  therefore, 
follow  the  example  of  the  majority  of  authors  in  devoting  con- 
siderable attention  to  the  so-called  neuroses  of  the  stomach 
and  intestines.  They  shall  be  discussed  under  the  three  heads, 
secretory,  sensory,  and  motor,  though  they  are  more  frequently 
considered  in  the  reverse  order.  It  is  my  belief  that  the  ex- 
cessive acid  secretion — hyperchlorhydria — which  I  have  found 
to  be  the  most  prevalent  of  all  gastric  derangements,  and  some 
degree  of  gastric  hypersesthesia,  which  frecjuently  occurs,  are 
the  chief  causes  of  the  common  motor  disturbances,  such  as 
spasms  of  the  cardia  and  pylorus,  cramps  or  colics  of  the  stom- 
ach, etc.  Hence  it  seems  to  me  appropriate  to  take  up  the 
derangements  of  secretion  first,  those  of  sensation  next,  and 
those  of  motility  last. 

The  Nervous  Secretory  Derangements  of  the  Stomach. — 
The  derangements  of  gastric  secretion  dependent  upon  in- 
flammatory conditions  have  been  considered  already  under  the 
heads  of  Asthenic  and  Sthenic  Gastritis.  "  Hyperchlorhydria 
and  Hypersecretion"  is  the  title  of  another  lecture  (LI.), 
in  which  I  have  discussed  Hyperchlorhydria,  Reichmann's 
Disease,  and  Gastroxynsis,  which  are  due  probably,  in  some 
cases,  to  obscure  nervous  conditions,  and  in  others  to  gastric 
or  duodenal  ulcer,  or  to  reflex  causes.  In  Lecture  XLIX.,  espe- 
cially, excessive  secretion  of  HCl  and  the  ferments  is  fully  dis- 
cussed.   There  is  little  left  to  be  said  about  the  many  derange- 

830 


GASTRIC    NEUROSES  83 1 

ments  of  secretion,  which  are  supposed  to  be  of  purely  neu- 
rosal  origin.  They  have  no  patliology,  their  aetiology  is  ob- 
scure, their  symptoms  are  virtually  the  same  as  those  of  the 
other  forms  of  abnormal  HCl  secretion,  and  the  treatment  of 
them  must  be  along  the  same  lines.  Whether  the  secretion  is 
excessive,  as  is  most  usual  in  nervous  conditions,  or  deficient, 
the  chief  difference  in  the  therapeutic  measures  applicable  is 
that,  the  affection  being  a  complication  or  direct  result  of 
neurasthenia,  the  measures  suitable  for  that  disease  must  sup- 
plement the  other  usual  remedies  for  the  deranged  secretion. 
Further  on,  in  Lecture  LXXVIL,  devoted  to  the  subject  of 
Nervous  Dyspepsia  (Neurasthenia  Gastro-Inte-stinalis),  the 
treatment  of  this  condition  will  be  found  somewhat  fully  con- 
sidered. Rest,  both  physical  and  psychic,  as  well  as  all  the 
practicable  strengthening  measures,  are  still  more  important 
than  in  the  other  forms  of  HCl  excess. 

Nervous  Hypochlorhydria  or  Gastric  Subacidity. — You 
will  encounter  many  cases  in  practice  showing  all  possible  de- 
grees of  HCl  deficiency,  and  in  quite  a  proportion  of  them  no 
other  cause  than  some  nerve  derangement  can  be  found.  If, 
after  having  performed  your  whole  duty  in  respect  of  thorough 
examinations  to  exclude  any  other  possible  lesion,  you  find  no 
tangible  cause  excep!:  neurasthenia,  your  proper  course  will  be 
to  build  up  the  system  in  eveiy  practicable  way  as  directed  for 
the  management  of  the  nervous  forms  of  hyperacidity,  and 
in  addition,  to  administer  small  or  moderate  doses  of  HCl, 
with  usually  pepsin  as  well,  unless  the  tests  have  shown  a 
sufficient  amount  of  the  latter.  But  do  not  prescribe  these 
until,  after  several  examinations,  you  have  become  convinced 
that  the  deficiency  of  HCl  is  more  than  a  passing  one,  to  be 
followed  in  a  few  days  by  a  normal  or  excessive  proportion  of- 
it.  Even  then,  do  not  continue  such  remedies  at  first  beyond 
one  week  without  testing  ^again,  for  in  such  neurasthenic 
cases,  the  glands  are  usually  very  impressionable  and  may  sud- 
denly respond  to  the  stimulation  of  the  HCl  and  pepsin  by  a 
hypersecretion,  which  is  likely  to  be  more  injurious,  if  it  per-< 


832  THE    GASTRO-INTESTINAL    CLINIC 

sists,  than  the  deficiency  would  be.  Indeed,  if,  for  any  reason 
tests  of  the  stomach  contents  cannot  be  made  at  least  every 
week  or  ten  days  at  first  during  such  a  course  of  treatment,  it 
will  be  wisest  to  refrain  from  prescribing  HCl  altogether,  and 
depend  upon  the  bitter  tonics,  especially  nux  vomica,  quassia, 
and  a  general  roborant  treatment. 

Hyperchlorhydria  Mistaken  for  Hypochlorhydria  with  a 
Serious  Result. — The  point  above  made  is  well  illustrated  by 
the  following  case  report: 


M.  K.,  aged  thirty-five,  a  stenographer  of  delicate  nervous 
temperament,  has  come  to  me  while  I  have  been  writing  this  lec- 
ture and  gives  the  following  history :  Six  weeks  ago,  after  a 
spell  of  unusual  physical  weakness,  she  began  to  suffer  from  a 
hot  and  uncomfortable  feeling  in  the  stomach,  coming  on  an 
hour  or  two  after  eating  and  persisting  often  for  several  hours. 
She  consulted  an  irregular  practitioner,  who  prescribed  tonics, 
including  HCl.  The  discomfort  then  steadily  increased,  and 
by  the  end  of  two  weeks  later  had  developed  into  such 
severe  pain  that  she  was  directed  to  remain  in  bed  and  limit 
herself  to  liquid  diet,  to  consist  of  beef  tea  and  milk.  The 
acid  was  continued  some  time  longer,  without  the  other  tonics. 
Later  the  diagnosis  of  gastric  ulcer  was  made,  and  the  acid 
medication  changed  to  small  doses  of  an  alkaline  one,  but  meat 
extractives  were  still  allowed  as  part  of  the  diet.  No  tests  of 
the  stomach  contents  were  made.  The  patient  is  now  able  to 
be  about,  but  still  suffers  pain  after  eating,  especially  after 
solid  food. 

Examination  at  my  office  revealed  the  usual  marked  tender 
spots  characteristic  of  gastric  ulcer,  and  this  being  still  so 
recent  a  development  I  decided  to  delay,  for  the  present,  the  in- 
troduction of  a  tube  for  the  purpose  of  getting  a  sample  of  the 
stomach  contents.  Excluding  meat  and  meat  extracts  or 
broths  from  the  diet  entirely,  and  limiting  her  to  milk  and 
Plasmon,  at  the  same  time  administering  alkalies  in  larger 
doses,  together  with  full  doses  of  bismuth,  have  relieved  the 
painfnl  symptoms  already  within  a  few  days.  The  patient  has 
meanwhile  been  kept  strictly  in  bed.  If  the  relief  had  not  been 
so  prompt  from  this  regime,  1  should  have  prescribed  rectal 
feeding  for  a  week  or  ten  days. 


GASTRIC    NEUROSES  833 

This  patient  at  first,  doubtless,  had  merely  an  acid  form  of 
dyspepsia,  /.  c,  hyperchlorhydria,  instead  of  hypochlorhydria 
as  the  physician  supposed.  If  he  had  established  this  fact  by 
a  stomach  test,  and  instead  of  hydrochloric  acid  and  meat  ex- 
tractives (the  two  most  powerful  stimulants  of  the  gastric 
glands),  had  prescribed  alkalies,  belladonna,  and  a  very  bland 
unstimulating  diet,  the  patient  would  have  been  spared  weeks 
of  sufifering,  to  say  nothing  of  the  loss  of  income  through  an 
illness  which  has  already  detained  her  from  her  occupation 
nearly  two  months,  and  will  probably  prevent  her  resuming 
it  for  another  month  or  two,  even  if  she  should  be  fortunate 
enough  not  to  require  a  laparotomy  to  bring  about  a  final  cure. 

Nervous   Anacidity   of  the   Stomach — Achylia   Gastrica 

Ewald,  sixteen  years  ago,  called  attention  prominently  to  the 
fact  that,  even  in  the  absence  of  any  discoverable  disease,  there 
may  be  a  total  lack  of  gastric  secretion,  or  at  least  achlorhydria 
with  hypopepsia.  He  named  this  condition  Anadenia  Gastrica, 
and  it  has  been  called  by  Einhorn  Achylia  Gastrica. 

Both  these  names  merely  imply  the  condition  of  a  total  or 
nearly  total  lack  of  gastric  secretion  without  involving  any 
theory  as  to  the  cause.  It  is  convenient  to  discuss  this  condi- 
tion among  the  neuroses,  though  it  by  no  means  always  results 
from  any  fault  in  the  nervous  system.  On  the  contrary,  it  is 
probably  most  frecjuently  either  a  consequence  of  organic  dis- 
ease in  the  stomach,  or  of  a  deficient  blood  supply  to  that 
organ  due  to  cardiac  asthenia  or  arteriosclerosis  of  the  gastric 
vessels. 

The  symptoms  of  anadenia  or  achylia  gastrica  depend  upon 
the  cause.  When  there  exists  a  true  atrophy  of  the  glands 
there  is  likely  to  be  much  impairment  of  the  health  with 
anaemia,  debility,  etc.,  from  a  lack  of  nutrition;  especially 
when,  at  the  same  time,  there  is  a  failure  of  the  intestinal  di- 
gestion, or  what  would  amount  to  the  same  thing,  a  lack  of 
propulsive  power  in  the  stomach  so  that  its  contents  cannot  be 
extruded  into  the  duodenum  in  time.  It  is  rare,  however,  that 
a  failure  of  gastric  motility  coincides  with  atrophy. 


834  THE    GASTRO-INTESTINAL    CLINIC 

Certain  writers  have  assumed  that  achyha,  or  rather  a  com- 
plete atrophy  of  the  gastric  glands,  is  the  most  frequent  cause 
of  pernicious  anaemia ;  but  this  theory  has  not  been  proved.  I 
have  seen  several  cases  of  achylia  in  which  the  patient  was  well 
nourished  and  complained  of  no  indigestion,  except  after  some 
marked  imprudence  in  eating  or  drinking.  Achylia  is  itself 
ohly  a  symptom — the  absence  of  gastric  secretion — and  may 
be  associated  with  various  diseases,  or  be  found  in  conditions 
of  apparent  health. 

The  diagnosis  can  only  be  made  from  a  test  of  the  stomach 
contents,  and  finding  not  merely  a  total  absence  of  HCl,  both 
free  and  combined,  but  also  of  the  rennet  ferment  and  its 
xymogen  as  well  as  the  inability  of  the  gastric  juice  to  digest 
albumin  even  when  0.2  per  cent,  of  HCl  has  been  added  to 
the  mixture,  showing  thus  absence  of  pepsin.  The  total  acidity 
will  not  be  over  10  or  12  in  a  case  in  which  the  failure  of  se- 
cretion is  complete,  and  is  often  less. 

The  treatment  must  be  directed  to  the  primary  disease, 
whatever  that  may  be.  When  it  is  neurasthenia,  the  remedies 
advised  in  Lecture  LXXVII.,  on  Nervous  Dyspepsia  (Gastro- 
intestinal Neurasthenia),  may  be  hopefully  followed,  and  in 
addition  it  is  often  well  to  add  a  mixture  containing  small  or 
moderate  doses  of  dilute  HCl  combined  with  some  efficient 
preparation  of  pepsin. 

I  have  observed  numerous  cases  in  which  for  months  or 
even  years  at  a  time  there  was  an  absence  of  all  the-  elements 
of  the  gastric  juice,  and  yet  finally  a  moderate  secretion  was 
re-established  as  a  result  of  such  a  course  of  treatment.  In  a 
large  proportion  of  these  it  is  bighly  probable  that  the  sup- 
pression of  the  secretion  was  due  to  some  nerve  fault ;  but  in 
one  of  them,  at  least,  the  cause  was  doubtless  the  prolonged  ad- 
ministration of  bicarbonate  of  sodium.  By  the  advice  of  a 
physician  who  did  not  make  a  practice  of  testing  the  stomach 
contents,  this  patient,  a  lady  aged  about  thirty,  took  regularly 
moderate  doses  of  the  soda  preparation  daily  for  a  period  of 
several  years,  both  in  this  country  and  during  an  absence  in 


GASTRIC    NEUROSES  835 

Europe,  and  when  she  came  under  my  care,  there  was  neither 
free  nor  combined  HCl  and  no  rennet  ferment.  She  took  by 
my  advice  HCl  and  pepsin  for  some  eight  months  before  the 
secretion  was  fully  restored.  In  several  cases  of  achylia  in 
elderly  persons,  I  had  reason  to  believe  that  there  was  atrophy 
of  the  glands,  and  in  some  of  them  this  diagnosis  was  con- 
firmed by  the  failure  of  even  HCl  and  pepsin  persevered  with 
for  several  years  (because  of  their  good  effects  in  a  palliative 
way)  to  restore  the  secretion.  In  others  again,  in  which  the 
achylia  may  have  been  due  to  nervous  causes  alone,  there  was 
finally  a  return  of  the  secretion  under  the  course  of  treatment 
which  included  5  to  10  minims  of  dilute  HCl  with  15  to  30 
minims  of  a  good  glycerol  of  pepsin  after  each  meal,  along 
with  a  generally  tonic  regimen. 

In  cases  of  undoubted  atrophy  it  is  not,  as  a  rule,  useful  to 
administer  HCl  as  a  remedy.  Better  results  have  usually,  in 
my  experience,  followed  the  abandonment  of  all  attempts  to 
re-establish  the  gastric  secretion  and  the  prescription  of  full 
doses  of  an  active  preparation  of  pancreas ;  but  whenever  there 
is  the  slightest  doubt  on  this  point,  I  believe  it  is  well  to  push 
the  administration  of  small  doses  of  the  HCl  with  pepsin  at 
intervals,  if  not  persistently,  for  at  least  one  year,  provided  it 
agrees  well,  since  after  an  even  longer  time  than  this  the  se- 
cretion has  sometimes  returned.  Cases  are  on  record  in  which 
there  has  been  a  restoration  of  the  secretion  after  as  long  a 
time  as  five  years,  but  in  these  cases  HCl  could  not  have  been 
administered  perseveringly  as  a  remedy,  since  it  is  unquestion- 
ably the  most  powerful  stimulant  we  have  for  the  gastric 
glands,  so  effective,  indeed,  that  if  it  is  to  bring  back  the  se- 
cretion at  all,  this  result  could  scarcely  be  postponed  so  long. 

SENSORY   DISTURBANCES   OF   THE    STOMACH:   GAS- 
TRALGIA,  GASTRIC    HYPER./ESTHESIA,  ETC. 

True  gastralgia  or  neuralgia  of  the  stomach  is  not  very 
often  encountered.  You  will  likely  see  many  more  cases  of 
acute  gastric  pain  due  to  hyperchlorhydria,  at  least  an  equal 


836  THE    GASTRO-INTESTINAL    CLINIC 

number  attributable  to  spasm  of  the  pylorus  or  gastric  cramps, 
and  nearly  as  many  in  which  the  cause  is  ulcer  or  cancer. 

The  name  gastralgia  should  be  applied  to  those  acute  stom- 
ach pains  only  which  occur  paroxysmally  without  regard  to 
the  character  or  amount  of  food  taken,  and  are  caused  by  a 
true  affection  of  the  nerves  of  the  stomach,  or  of  the  centers 
from  which  they  arise,  and  not  to  any  of  the  numerous  similar 
pains  which  may  result  from  a  diseased  condition  of  some  of 
the  other  structures  of  the  viscus. 

The  Aitiology  of  Gastralgia. — The  affection  can  arise  from 
any  of  the  causes  that  are  likely  to  produce  neuralgia  in  nerves 
elsewhere.  These  include  malaria,  syphilis,  gout,  anaemia, 
hysteria,  neurasthenia,  and  systemic  poisoning  by  tobacco,  lead, 
mercury,  or  other  of  the  metals.  According  to  some  authors 
the  pains  that  may  be  produced  in  the  stomach  by  perigastritis 
and  organic  diseases  of  the  stomach  itself,  as  well  as  by  the 
reflex  gastric  pains  from  displacements  of  any  of  the  viscera 
or  various  diseases  in  distant  parts  as  in  the  genito-urinary 
organs  of  either  sex,  etc.,  are  classed  among  the  gastralgias; 
but  I  cannot  see  that  any  useful  purpose  is  subserved  by  giving 
to  the  word  gastralgia  so  broad  a  significance.  Call  the  other 
gastric  pains  of  obscure  origin  by  the  name  of  gastrodynia  if 
you  will,  but  let  us  keep  the  word  gastralgia  to  describe  a  true 
neuralgia  of  the  stomach  nerves.  Various  diseases  of  the 
central  nervous  system  can  produce  gastralgia.  Cerebral  af- 
fections are  exceptionally  the  cause  of  it,  but  those  of  the 
spinal  cord  more  often,  including  certain  forms  of  mye- 
litis, and  tabes  dorsalis  produces  a  comparatively  frequent 
manifestation  of  gastralgia,  known  familiarly  as  gastric 
crises. 

The  syiupfonis  of  Gastralgia  are  much  the  same  as  those  of 
other  forms  of  neuralgia.  The  pain  comes  on  in  paroxysms 
lasting  from  half  an  hour  to  several  hours,  and  is  generally 
severe,  often  intolerable,  so  that  relief  by  hypodermics  of  mor- 
phine is  urgently  demanded.  It  may  be  shooting,  boring,  tear- 
ing, or  burning  in  character.     Unlike  most  other  gastric  pains 


GASTRIC    NEUROSES  837 

it  is  usually  relieved,  to  some  extent  at  least,  by  firm  pressure 
upon  the  epigastrium,  though  there  are  often  very  sensitive 
spots  in  the  middle  line  over  the  sympathetic  nerve  plexuses. 
The  pain  may  radiate  in  any  direction,  but  especially  toward 
the  spine  or  downward  into  the  hypochondria.  Attacks  of 
gastralgia  do  not  recur  with  any  regularity,  nor  can  they 
often  be  traced  to  any  special  provocation,  though  sometimes 
mental  strain  or  excitement  precedes  them.  In  the  severer 
ones  the  patient  suffers  acutely ;  the  face  is  contorted,  the  coun- 
tenance expressing  great  suffering,  and  cold  sweat  may  appear 
upon  the  skin. 

The  diagnosis  of  Gastralgia  is  not  always  easy,  and  can 
often  be  made  only  by  exclusion.  In  the  absence  of  the  symp- 
toms and  signs  of  ulcer,  chemical  findings  showing  hyper- 
chlorhydria  or  other  form  of  HCl  excess,  paroxysms  of  vio- 
lent pain  in  the  stomach  occurring  irregularly,  independently 
of  the  digestive  periods,  and  leaving  the  patient  entirely  free  of 
any  discomfort  in  the  intervals,  may  be  set  down  as  probably 
due  to  gastralgia.  Carcinoma  of  the  stomach  may  possibly 
produce  spells  of  similar  pain,  but  is  much  less  likely  to  do 
so  than  the  other  affections  named,  and  there  would  not  then, 
as  a  rule,  be  such  entire  freedom  from  discomfort  between 
times.  Gall-stones  cause  extremely  violent  pains  in  the  region 
of  the  gall  bladder,  and  may  be  confounded  with  gastralgia, 
but  the  pains  are  usually  referred  to  a  point  much  further 
to  the  right  than  those  of  gastralgia  and  are  not  relieved  in  the 
least  by  pressure.  Moreover  they  are  generally  accom- 
panied by  symptoms  of  obstruction  of  the  bile  duct — jaundice, 
high-colored  urine,  pale  clay-colored  stools — and  usually  also 
by  a  swelling  in  the  region  of  the  gall  bladder,  as  well  as  by 
more  or  less  fever,  though  this  may  often  be  wanting.  Atypi- 
cal cases  of  biliary  colic  may  be  impossible  to  differentiate 
from  gastralgia,  and  you  must  then  decide  by  the  results  of 
the  treatment  for  the  latter.  The  diagnosis  from  hyper- 
chlorhydria,  ulcer,  and  cancer  will  readily  be  made  by  compar- 
ing the  symptoms  and  signs  of  those  diseases  as  described  in 


838  THE    GASTRO-INTESTINAL    CLINIC 

previous  lectures.  In  hyperchlorhydria  the  pain  is  relieved  by 
more  food ;  in  ulcer,  increased  by  food ;  but  in  gastralgia,  has 
no  relation  at  all  to  food.  Muscular  rheumatism  could  scarcely 
be  confounded  with  gastralgia,  since  the  pain  is  not  paroxys- 
mal nor  violent.  Intercostal  neuralgia  may  cause  a  similar 
kind  of  pain,  but  in  such  cases  the  affected  nerve  will  be  sensi- 
tive to  superficial  pressure,  not  only  at  the  locality  where  the 
pain  is  felt,  but  usually  at  various  points  all  the  way  around  to 
its  spinal  origin.  The  diagnosis  from  any  of  the  conditions 
involving  excessive  secretion  of  HCl  with  the  acute  pains  and 
motor  spasms  frequently  resulting  therefrom,  can  easily  be  de- 
termined by  examinations  of  the  gastric  juice,  repeated  if 
necessary.  A¥hen  for  any  reason  these  cannot  be  made,  the 
makeshifts  for  determining  otherwise  approximately  the  pro- 
portion of  HCl  in  the  gastric  juice  may  be  resorted  to,  and 
will  sometimes  help  you  to  decide.  (See  Lecture  IX.)  Then, 
too,  the  regular  recurrence  of  the  pain  at  the  height  of  diges- 
tion, relieved  by  taking  more  food  and  passing  off  entirely  as 
a  rule  when  the  digestion  has  ended,  presents  a  picture  in 
hyperchlorhydria  and  allied  conditions,  totally  different  from 
that  I  have  just  shown  you  as  characteristic  of  gastralgia. 
The  cramp  pains  occurring  in  pyloric  spasm  usually  persist  till 
the  stomach  has  been  emptied  either  through  the  pylorus,  or  by 
vomiting,  and  recur  after  the  next  full  meal. 

Treatment  of  Gastralgia. — Your  chief  object  in  this  respect 
should  be  to  ascertain  as  certainly  as  possible  the  nature  of 
the  primary  disease,  and  then  so  shape  the  treatment  as  to  re- 
move or  control  it.  When  the  attacks  are  of  unusual  severity, 
the  pain  must  of  course  be  relieved  in  some  way — by  the  ad- 
ministration of  morphine — even  hypodermically,  if  necessary; 
but,  if  possible,  other  less  harmful  remedies  should  be  first  tried. 
A  turpentine  stupe  or  hot  mush  poultice  will  generally  lessen 
the  pain  decidedly,  or  what  is  often  just  as  effective  and  not 
nearly  so  troublesome  is  a  very  hot,  w'et  compress,  applied  so 
hot  that  a  layer  or  two  of  flannel  will  need  to  be  placed  be- 
tween it  and  the  patient.     The  whole  should  then  be  covered 


GASTRIC    NEUROSES  839 

by  three  or  four  thicknesses  of  cloth,  inchiding,  if  practicable, 
one  layer  of  some  impervious  material  so  as  to  confine  the  mois- 
ture and  prevent  evaporation  or  a  too  rapid  cooling.  Such  an 
application,  fastened  firmly  to  the  abdomen  by  a  binder  passing 
all  the  way  around  the  body,  will  often  control  an  attack  of 
even  very  severe  gastralgia  or  other  abdominal  pain  as  ef- 
fectually almost  as  an  opiate,  without  any  of  the  unpleasant 
effects  of  the  latter.  When  morphine  must  be  injected,  it  is 
best  to  combine  with  each  ^  grain  of  the  latter  i-ioo  to  1-80 
grain  of  atropine  sulphate,  since  the  combination  is  likely  to 
disturb  the  stomach  very  much  less  than  would  morphine 
alone,  and  is  also  more  powerfully  antispasmodic. 

The  systemic  treatment  to  be  pursued  between  the  attacks, 
depends,  of  course,  very  much  upon  the  character  of  the  pri- 
mary disease.  When  this  has  resulted  from  any  specific  in- 
fection, such  as  malaria,  quinine  is  naturally  the  very  best 
remedy  of  all,  and  it  has  even  been  found  effective  in  other 
forms  of  gastralgia  in  which  there  has  been  no  suspicion  of 
malaria.  Syphilis  and  the  metallic  poisons  call  for  potassium 
iodide  in  full  doses.  Lithsemia  or  obscure  forms  of  gout  de- 
mand alkalies  and  deobstruents  with  more  exercise  and  less 
rich  food.  Anaemia,  chlorosis,  and  the  other  depressed  con- 
ditions including  neurasthenia  and  hysteria  are  benefited  by 
iron,  arsenic,  and  often  by  phosphorus,  the  hypophosphites  or 
the  glycerophosphates.  All  the  other  tonic  or  building-up 
measures,  such  as  country,  mountain,  or  seashore  air  (es- 
pecially the  last,  which  often  acts  almost  magically),  well-se- 
lected hydriatic  procedures,  and  above  all,  electricity,  are  par- 
ticularly indicated  in  these  latter  classes  of  cases.  Full  doses 
of  galvanism  (20  to  30  ma.)  applied  directly  through  the 
'region  of  the  stomach  from  the  back  to  the  front  with  the 
positive  pole  over  the  epigastrium,  and  repeated  every  other 
day  at  least,  or  better  yet,  half  these  doses  applied  intragas- 
trically,  will  usually  prove  effective,  and  sometimes  will  even 
relieve  the  paroxysms  of  pain.  For  the  latter,  too,  the  new 
method  by  mechanical  vibration,  applied  with  moderate  pres- 


840  THE    GASTRO-INTESTINAL    CLINIC 

sure  directly  over  the  seat  of  pain,  is  well  worth  a  trial  in  such 
cases,  since  it  often  proves  effective  in  relieving  neuralgic  pains, 
both  when  applied  over  the  site  of  the  pain  and  upon  that  part 
of  the  spine  from  which  the  structure  involved  receives  its  nerve 
supply.  The  static  sparks  and  electrostatic  currents  are  often 
effective  here  also. 

When  the  pain  is  a  reflex  from  disease  in  the  genito-urinary 
system,  or  in  any  other  distant  organ,  the  affected  part  must 
receive  the  chief  attention,  and  naturally  any  local  disease  or 
unhygienic  practices  which  are  keeping  up  irritation  must  be 
corrected. 

Gastric  Hyperaesthesia. — In  many  diseases  of  the  stomach, 
especially  in  the  different  forms  of  gastric  catarrh,  in  liyper- 
chlorhydria,  etc.,  pain  or  discomfort  is  experienced  in  the 
viscus,  and  the  sensory  nerve  terminals  are  believed  in  such 
cases  to  be  unduly  sensitive.  There  is  certainly  a  wide  dif- 
ference between  the  complaints  of  abnormal  sensations  in 
some  severe  cases  of  the  kinds  mentioned,  and  those  made  by 
the  patients  in  other  like  conditions  of  a  far  milder  degree — 
not  that  the  complaints  in  the  former  are  greater,  as  you  would 
naturally  expect  them  to  be,  but  often  markedly  less.  For  ex- 
ample, I  exceptionally  encounter  cases  of  acid  gastritis  with  a 
percentage  of  free  HCl  above  0.2  withoiit  any  symptoms  what- 
ever, and  then  sometimes  see  cases  in  which  there  is  only  a 
very  slight  catarrhal  process  and  a  percentage  of  free  HCl  not 
ever  0.09  per  cent.,  with  complaints  of  burning  or  other 
markedly  disagreeable  sensations  during  the  height  of  the  pe- 
riod of  digestion.  Again,  in  consequence  of  a  long-standing 
chronic  atrophic  catarrh,  with  virtually  no  gastric  juice  left  in 
certain  cases,  there  will  be  complaints  of  burning  sensations 
after  the  administration  of  very  moderate  doses  of  HCl,  unless 
it  is  largely  diluted  and  sipped  slowly  during  the  course  of  an 
hour  or  two.  Indeed,  I  have  most  frequently  encountered  such 
a  manifest  hyperccsthesia,  against  acids  especially,  in  cases  in 
which  there  has  been  complete  achylia. 

Yet,  if  we  were  to  accept  tlie  view  of  gastric  hyperaesthesia 


GASTRIC    NEUROSES  84I 

given  by  Riegel,  all  such  instances  of  the  condition  as  are 
above  described  would  have  to  be  excluded  entirely.  After 
accurately  defining  this  affection  as  "  a  morbidly  increased 
sensibility  of  the  sensory  nerves  of  the  stomach,"  he  goes  on 
to  say:  "  Hypersesthesia  is  characterized  by  a  variety  of  ab- 
normal sensations — a  feeling  of  pressure,  fullness,  tension, 
burning,  boring,  etc.,  during  digestion.  As  a  rule,  these  sensa- 
tions persist  for  some  time  after  digestion.  Abnormal  sensa- 
tions of  the  kind  are  encountered  in  the  majority  of  organic 
diseases  of  the  stomach.  These  of  course  we  are  not  discuss- 
ing in  this  place.  The  same  abnormal  sensations  are  occa- 
sionally seen  as  complications  or  symptoms  of  hysteria,  neu- 
rasthenia, and  a  number  of  diseases  of  the  central  nervous 
system.  In  anaemia  and  chlorosis  we  also  occasionally  en- 
counter hyperccsthesia.  In  the  latter  cases  we  are  by  no  means 
justified,  however,  in  declaring  the  hypersesthesia  to  be  a  true 
neurosis  of  the  stomach,  for  we  may  only  diagnose  this  con- 
dition if  the  stomach  is  intact,  and  in  chlorosis  and  anaemia,  as 
we  know,  we  frecjuentl}^  see  perversions  of  gastric  secretion,  in 
particular  hyperchlorhydria,  so  that  the  latter  alone  may  be 
made  responsible  for  the  abnormal  sensations,  and  may  even 
pioduce  attacks  of  cardialgia."' 

Accepting  Riegel's  definition  of  gastric  hypersesthesia,  "  a 
morbidly  increased  sensibility  of  the  sensory  nerves  of  the 
stomach,"  and  it  cannot  well  be  improved,  it  seems  logical  to 
include  under  it  all  the  cases  of  unduly  heightened  sensibility 
of  the  gastric  nerve  endings,  in  which  comparatively  trivial 
causes  produce  an  exaggerated  amount  of  sensation,  in  spite 
of  the  fact  that  there  is  an  associated  organic  lesion.  It  is 
well  known  and  admitted  by  Riegel  himself,  elsewhere  in  his 
great  work  on  the  stomach,  that,  in  a  large  proportion  of  the 
gastric  affections  which  we  usually  class  as  nervous,  there  ex- 
ists some  real  lesion  which  by  our  present  methods  we  are  un- 
able to  discover,  but  even  admitting  that  there  may  be  cases  of 
hypersesthesia  dependent  wholly  upon  a  fault  in  the  nerves 
themselves,   whether  it  be  in  a  nerve  center,  trunk,   or  ter- 


842  THE    GASTRO-INTESTINAL    CLINIC 

minal,  we  need  some  term  to  describe  also  the  numerous 
symptom  groups  in  which,  along  with  a  relatively  slight 
lesion,  there  is  an  altogether  exaggerated  sensibility  of  the 
nerves. 

The  diagnosis  of  gastric  hypersesthesia  is  made  from  the 
single  symptom  that  with  either  no  determinable  gastric  le- 
sfon,  or  one  of  slight  or  moderate  character,  there  are  com- 
plaints of  discomfort  or  pain  after  eating,  which  is  apparently 
causeless,  or,  if  disease  be  found,  out  of  proportion  to  the 
amount  of  such  disease.  There  is  usually  some  sensitiveness 
on  pressure  over  all  that  part  of  the  stomach  which  is  below 
the  ribs,  but  this  is  not  marked  anywhere,  and  there  is  lacking 
especially  the  acute  tenderness  over  circumscribed  spots  demon- 
strable in  ulcer.  Though  considered  by  some  to  be  closely 
related  to  gastralgia,  it  should  be  easily  differentiated  from  the 
latter  by  the  uniform  dependence  of  the  pain  upon  eating, 
while  gastralgia  may  come  on  in  parox3^sms  at  any  time,  re- 
gardless of  meals.  Besides,  the  pain  in  the  latter  affection  is 
often  intense,  severe,  while  that  of  hypersesthesia  is  usually 
slight — often  not  more  than  a  decided  discomfort.  It  might 
be  confounded  with  the  dull  pain  and  tenderness  often 
seen  in  chronic  gastritis  if  no  examination  of  the  stomach 
contents  could  be  made,  but  the  findings,  chemic  and 
microscopic,  in  such  an  examination  would  reveal  the  true 
condition. 

Treatment  of  hypersesthesia  should  be  based  mainly  upon 
the  nervous  element  which  is  always  present.  Galvanism  from 
the  spine  to  the  epigastrium,  with  a  short  application  addi- 
tionally to  the  vagi  in  the  neck,  rarely  fails  to  accomplish  much. 
Galvanism  or  high-tension  faradism  applied  within  the  stom- 
ach, by  means  of  the  intragastric  electrode,  is  still  better  for  all 
except  the  very  few  who  are  intolerant  of  any  instrument  in 
that  viscus. 

Spraying  with  a  weak  nitrate  of  silver  solution  (o.i  per 
cent.),  or  a  menthol  solution,  and  in  stubborn  cases  with  a 
combination  of  menthol  and  cocaine,  is  generally  effective.    Hot 


GASTRIC    NEUROSES  843 

compresses,  as  advised  for  gastralgia,  may  be  kept  on  con- 
tinuously at  night  with  advantage. 

The  following  prescription  has  often  proved  very  helpful  to 
my  patients  suffering  from  this  affection : 
Argent,  nitrat. 


T^  ^  .     r  aa gr.  IV 

Ext.  nuc.  vomic.  )  ^ 

Ext.  belladon gr.  i 

Ext.  taraxaci 3i. — 3ii 

Bismuth  subuit 3  i 

M.   et  ft.  mass,   in  pil.   No.   XX  dividend. 

Sig.     One  before  each  meal. 

In  addition  to  the  above-mentioned  local  remedies,  the  medi- 
cines and  measures  described  in  Lecture  LXXVII.  as  suitable 
for  nervous  dyspepsia  (gastro-intestinal  neurasthenia)  are  in- 
dicated in  gastric  hypersesthesia.  Like  the  neuroses  of  the 
stomach,  generally,  it  might  be  considered  under  the  head  of 
nervous  dyspepsia,  but  there  are  reasons  already  stated  for 
giving  to  some  of  them  separate  consideration. 

Other  Abnormal  Sensations  in  the  Stomach. — In  health  one 
does  not  have  any  sensations  in  the  stomach  except  the  pleas- 
urable one  of  a  comfortable  satiety  after  a  full.  meal.  In 
various  diseased  conditions,  especially  in  neurasthenia, 
whether  there  be  any  pathologic  change  in  the  organ  or  not, 
unpleasant  sensations  of  one  kind  or  another  are  frequently 
experienced.  In  addition  to  the  various  degrees  of  pain  in  the 
stomach  described  under  the  heads  of  Gastralgia  and  Gastric 
Hyperccsthesia,  and  to  the  pains  arising  from  pathologic 
states,  a  symptom  frequently  described  by  patients  is  a  feel- 
ing' of  weight  or  heaviness  coming  on  regularly  after  eating. 
This  is  probably  almost  invariably  due  to  atony  of  the  stomach 
walls,  whether  associated  with  dilatation  of  the  viscus  or  not ; 
■but  it  is  claimed  by  some  authors  that  the  same  sensation  is 
sometimes  encountered  as  the  result  of  a  neurosis  merely,  and 
I  therefore  mention  it  in  this  connection,  though  doubtful 
whether  it  ever  occurs  when  the  gastric  motility  is  entirely 
normal.  Other  abnormal  sensations  which  may  undoubtedly 
be  of  nervous  origin  are  a  feeling  of  heat  or  cold  in  the  stom- 


844  THE    GASTRO-IXTESTINAL    CLINIC 

ach  after  eating,  and  especially  nausea.  The  latter  symptom  I 
have  seen  so  often  in  women  quite  independently  of  any  demon- 
strable gastric  lesion  that  I  am  convinced  it  very  frequently 
depends  upon  a  reflex  cause,  the  real  lesion  being  most  fre- 
quentlv  in  the  sexual  organs,  particularly  in  women  (who 
nearly  monopolize  the  symptom),  or  else  upon  a  pure 
neurosis. 

Xausea  of  such  a  reflex  or  nervous  type  never  yields  to  any 
medicine  addressed  to  the  stomach.  In  a  number  of  women 
patients  afflicted  at  times  with  this  trouble,  I  have  found  the 
cause  to  be  an  irritation  of  the  uterus  or  ovaries,  and  it  is  al- 
ways much  aggravated  at  the  menstrual  periods.  In  some  of 
these  cases  the  particular  fault  has  been  a  backward  displace- 
ment which,  failing  the  patient's  consent  to  a  curative  opera- 
tion, the  g}'necologist  has  tried  to  keep  in  place  without  a  pes- 
sary, and  with  only  partial  success.  The  bromides  will  some- 
times relieve  temporarily,  but  all  drugs  may  fail  till  the  cause 
has  been  removed.  Tonic  measures  and  medicines  are  usually 
indicated,  as  in  all  the  neuroses. 

Hemicrania  or  migraine  and  intercostal  neuralgia  are  other 
sensory  disturbances  which  Fleiner  has  considered  in  this  con- 
nection, because  they  are  frequently  dependent  upon  faulty 
stomach  conditions.  But.  though  these  are  often  due  to  gastro- 
intestinal disease,  especially  migraine,  they  are  more  appro- 
priately considered  elsewhere.  They  no  more  belong  here  than 
epilepsy,  neurasthenia,  eczema,  etc.,  which  often  have  a  gastro- 
intestinal cause. 

DERANGEMENTS   OF   THE   APPETITE 

These  may  be  due  to  organic  lesions  or  to  an  excess  or  de- 
ficiency of  the  gastric  juice,  or  be  merely  dependent  upon  a 
disturbed  condition  of  sensation  in  the  stomach.  According 
to  my  experience,  an  abnormally  large  appetite  has  been  most 
frequently  seen  in  connection  with  either  an  increased  secre- 
tion of  HCl,  or  else  with  an  excessive  amount  of  the  organic 
acids  resulting  from  a  catarrhal  condition,  or  from  a  deficient 


GASTRIC    NEUROSES  845 

gastric  motility ;  and  anorexia  has  been  rather  constantly  asso- 
ciated with  a  lack  of  secretion  or  motility  or  both,  though  ex- 
ceptionally I  have  seen  it  coincide  with  hyperchlorhydria.  But 
there  are  many  cases  which  we  must  attribute  to  nervous 
causes. 

Bulimia  and  Akoria. — Bulimia  is  an  exaggerated  or  almost 
unappeasable  hunger,  sometimes  called  canine  hunger.  Akoria 
is  a  lack  of  the  normal  feeling  of  satiety  after  eating  an  abun- 
dant meal.  The  two  conditions  are  closely  allied,  and  when 
a  person  habitually  eats  far  too  much,  it  is  often  impossible  to 
decide  whether  his  excess  in  this  respect  is  due  to  the  one  or 
the  other  fault.  As  a  rule  the  two  apparently  go  together,  for 
it  is  exceedingly  rare  that  one  is  impelled  to  go  on  eating  after 
a  feeling  of  fullness  has  been  reached. 

The  term  bulimia  is  commonly  applied  to  an  abnormally 
great  appetite,  one  which  is  out  of  proportion  to  the  demands 
of  the  system,  regardless  of  the  cause.  Naturally  the  growing 
child  and  youth  require  more  food  than  the  full-grown  adult, 
and  the  pregnant  or  nursing  woman  more  than  she  who  does 
not  have  to  "  eat  for  two."  In  like  manner  the  convalescent 
from  a  fever  or  other  serious  disease  has  a  normally  in- 
creased appetite,,  and  the  man  who  works  out  in  the  open  air 
for  ten  or  twelve  hours  a  day,  as  farmers  and  laborers  often  do, 
not  to  speak  of  soldiers  on  forced  marches,  needs  two  to  three 
times  the  amount  of  food  which  will  suffice  for  the  idle  indoor- 
dweller.  In  estimating  whether  the  amount  of  food  taken  is 
excessive,  these  differences  must  always  be  taken  into  the 
account. 

But  when  a  person  not  in  any  one  of  the  above-mentioned 
classes,  who  is  not  actively  using  his  muscles  for  many  hours 
ciaily,  eats  exceptionally  large  meals  without  feeling  fully  sat- 
isfied, or  if,  after  a  feeling  of  satiety,  within  an  hour  or  so 
again  experiences  a  sharp  sensation  of  hunger  which  impels 
him  to  demand  imperatively  more  food  and  drink,  you 
may  know  that  the  appetite  is  an  abnormal  one  and  should 
take  measures  to  remedy  the  diseased  condition  upon  which  it 


846  THE    GASTRO-INTESTINAL    CLINIC 

depends.  Most  frequently  this  will  be  either  a  simple  hyper- 
chlorhydria,  or  some  one  of  the  various  forms  of  excessive 
secretion  of  HCl,  which  you  can,  in  most  cases,  easily  deter- 
mine by  examining  the  gastric  contents  after  a  test  meal.  If 
such  a  hypersecretion  be  found,  the  appropriate  treatment — 
alkalies,  sedatives,  intragastric  electricity  with  the  high-ten- 
sion farad ic  current,  etc. — will  usually  prove  effective  in  curing 
the  bulimia  in  the  same  degree  that  it  succeeds  in  remedying 
the  primary  disease.  When  there  is  gastritis  with  either  too 
much  HCl  or  too  little  of  the  latter,  but  then  with  an  excess  of 
the  organic  acids  which  unduly  irritate  the  gastric  nerve 
endings  and  thus  cause  excessive  hunger,  the  cure  will  be 
much  helped  by  washing  out  the  patient's  stomach  daily  or 
every  other  day. 

In  other  cases  the  excessive  appetite  may  be  due  to  worms 
or  to  diabetes,  and  then,  of  course,  the  first  thing  to  do  will  be 
to  treat  by  suitable  measures  these  underlying  diseases. 

When,  on  the  other  hand,  the  bulimia  is  consequent  upon 
some  obscure  nervous  lesion,  as  in  epilepsy,  certain  states  of 
defective  intelligence,  or  any  fault  of  the  nervous  system,  the 
task  will  be  more  difficult.  In  some  of  these  cases  a  systematic 
limitation  of  the  amounts  of  food  to  be  taken  is  necessary,  and 
all  eating  between  meals  must  be  strictly  forbidden ;  the  ap- 
petite can  thus  be  gradually  trained  to  correspond  more  nearly 
with  the  normal  requirements.  In  stubborn  cases  it  is  ad- 
visable to  apportion  not  only  the  kinds  of  food  to  be  eaten, 
but  precisely  the  amounts  of  each  kind  based  upon  the  tables 
showing  the  number  of  calories  or  heat  units  required  for  a 
person  not  actively  exercising  and  the  normal  proportions  of 
proteids,  fats,  carbohydrates,  and  salts  needed  to  maintain  nu- 
trition.  (See  Lecture  XVI.)  Meanwhile,  of  course,  any  dis- 
coverable fault  or  vice  of  the  organism  should  be  combated  by 
appropriate  measures. 

The  Buccal  Reflex. — Horace  Fletcher,  a  layman,  who  has 
made  a  more  profound  study  of  the  appetite  in  relation  to 
mastication,   digestion,   nutrition,  etc.,   than  most  physicians, 


GASTRIC    NEUROSES  84/ 

maintains  in  a  very  interesting  book  recently  published^  that 
the  majority  of  persons  eat  at  least  twice  as  much  as  they  re- 
quire, and  claims  to  have  discovered  that  the  buccal  reflex 
which  should  guide  us  in  the  length  of  time  we  chew  our  food, 
and  the  amounts  eaten  by  us,  has  been  lost  or  perverted  in  the 
case  of  most  human  beings.  He  holds  that  food  should  be 
masticated,  or  in  the  case  of  liquid,  kept  moving  about  in  the 
mouth,  till  it  has  been  so  thoroughly  insalivated  as  to  become 
alkaline,  when  only,  under  normal  conditions,  the  muscies 
about  the  fauces  will  open  and  permit  it  to  be  swallowed.  As 
a  result  of  hasty  and  excessive  eating,  with  insufficient  insaliva- 
tion  supplemented  by  drinking  to  wash  down  the  imperfectly 
insalivated  boluses,  the  natural  buccal  reflex  is  lost.  To  re- 
store this  lost  reflex  and  prevent  gluttonous  eating,  Fletcher 
advises  systematic  overmastication  of  every  portion  of  food, 
solid  or  liquid,  taken  into  the  mouth,  the  attention  being  mean- 
while concentrated  upon  the  act,  and  claims  that  if  this  be 
practiced  faithfully  for  from  four  to  six  weeks,  the  lost  reflex 
will  be  regained,  after  which  there  will  be  neither  appetite  for 
more  food  than  the  body  requires,  nor  the  ability  to  swallow 
(without  forcing  it)  any  morsel  that  has  not  been  properly 
masticated  and  insalivated. 

The  Proper  Food  Ration. — Fletcher  is  an  American  who 
has  been  carrying  out  scientific  investigations  and  experiments 
upon  this  subject  in  Venice  (Italy),  and  Cambridge  University 
(England),  as  well  as  at  Yale  University  (New  Haven),  in  co- 
operation with  a  number  of  prominent  physiologic  chemists 
and  other  medical  men.  The  results  demonstrated  by  these  ex- 
periments, particularly  the  smallness  of  the  amount  of  food 
which  could  be  made  to  maintain  a  complete  nutritive  equili- 
brium, when  overmastication  as  advised  by  Fletcher  was  prac- 
ticed, are  described  in  Lecture  XVI.,  on  Prophylaxis,  etc. 
They  are  very  striking  and  exceedingly  interesting.  Fletcher 
refers  also  to  a  similar  experiment  as  to  the  proper  food  ration 

'"The  A  B-Z  of  Our  Own  Nutrition,"  New  York,  Frederick  A. 
Stokes  Co.,  1903, 


848  THE    GASTRO-INTESTINAL    CLINIC 

recently  undertaken  at  Yale  University  under  the  auspices  of 
the  United  States  Government,  a  number  of  enlisted  members 
of  the  Hospital  Corps,  who  volunteered  for  the  purpose,  being 
the  subjects. 

These  experiments  are  highly  important,  since  the  conclu- 
sions of  Voit  and  others,  as  to  the  normal  food  requirements 
of  man,  have  not  finally  settled  the  question. 

Anorexia  and  Hyperkoria. — Anorexia  is  a  lack  of  appetite, 
and  hyperkoria,  the  opposite  of  akoria,  is  the  coming  on  of  a 
feeling  of  fullness  or  satiety  too  soon — after  the  ingestion  of  an 
insufficient  quantity  of  food.  As  in  the  opposite  conditions, 
these  are  often  associated,  and  it  may  be  impossible  to  tell 
which  predominates  in  some  cases  when  too  little  nourishment 
is  regularly  taken. 

Although  we  would  naturally  expect  a  deficient  appetite  and 
deficient  gastric  secretion  to  go  together,  we  by  no  means  al- 
ways find  them  so.  \Miile,  as  a  rule,  a  lack  of  gastric  juice  is 
accompanied  by  a, lack  of  appetite,  I  have  seen  many  cases  in 
which  the  appetite  has  been  good  in  spite  of  a  persistent 
achylia  gastrica.  So,  too,  anorexia  is  generally  accompanied 
by  a  deficient  secretion  of  the  gastric  juice,  but  by  no  means 
always.  There  are  many  depressed  nervous  or  psychic  con- 
ditions in  which  tbe  patient  runs  down  in  health  from  insuffi- 
cient food,  or  can  only  with  great  difficulty  be  induced  to  eat 
enough  to  maintain  nutrition,  in  spite  of  the  fact  that  the  gas- 
tric secretion  is  sufficient.  I  believe,  however,  that  an  exami- 
nation of  the  stomach  contents  in  all  the  cases  of  nervous  ano- 
rexia would  show  that  in  most  of  them  the  HCl  and  ferments 
are  almost  constantly  much  below  normal,  though  the  fre- 
quent improvement  of  such  cases,  under  remedies  addressed  to 
the  nervous  system  or  mental  state  alone,  might  seem  to  prove 
the  contrary.  In  these  cases  both  the  deficient  secretion  and 
deficient  appetite  are  results  of  the  systemic  depression,  and 
when  this  is  removed  by  whatever  cause,  both  the  secretory 
fault  and  the  consequent  anorexia  are  overcome. 

In  addition  to  the  faults  in  the  stomach  itself,  such  as  a 


GASTRIC    NEUROSES  849 

lack  of  secretion,  lowered  motility,  chronic  gastric  catarrh, 
and  cancer,  various  systemic  affections,  such  as,  e.  g.,  tubercu- 
losis and  many  other  diseases,  tend  to  decrease  the  appetite. 
Anorexia  is  often  a  consequence,  too,  of  certain  little  under- 
stood nervous  conditions.  As  already  mentioned,  psychic 
depression  from  whatever  cause  may  take  away  all  appetite. 
Grief,  worry,  anxiety,  the  fear  of  pain,  and  merely  overstrain 
with  the  resulting  profound  debility  and  neurasthenia  are 
quite  capable  of  setting  up  the  condition. 

The  symptoms  of  nervous  anorexia  are  a  marked  distaste  for 
food  and  a  steadily  increasing  debility  and  emaciation  in  the 
absence  of  any  organic  affection  capable  of  producing  such  a 
lowering  of  the  health. 

The  diagnosis  is  equally  simple  and  w^ould  seem  well-nigh 
unmistakable.  When  no  real  lesion  is  to  be  found,  and  the  pa- 
tient persistently  refuses  to  take  an  adequate  amount  of  food, 
the  cause  can  only  be  nervous  or  psychic. 

The  treat  men  f,  which  in  the  beginning,  before  the  loss  of 
nutrition  has  gone  too  far,  is  nearly  always  successful,  con- 
sists, first  of  all,  in  imperatively  requiring  the  patient  to  take 
more  food.  At  the  same  time,  every  effort  should  be  made  to 
tempt  the  appetite  with  a  variety  of  toothsome  dishes,  as  well 
as  to  stimulate  it  by  means  of  stomachics.  For  the  latter  pur- 
pose I  have  found  a  combination  of  the  tincture  of  nux  vomica, 
or  of  quassia,  with  pepsin  and  HCl  the  most  effective  of  all  the 
drugs  at  our  command,  especially  for  the  great  majority  of 
cases  in  which  the  cause,  whatever  it  may  chance  to  have  been, 
has  lessened  the  secretion  of  the  gastric  juice  at  the  same  time 
that  it  has  taken  away  the  appetite.  The  majority  of  authors, 
it  seems  to  me,  have  not  given  sufficient  prominence  to  the 
very  valuable  part  that  HCl  and  pepsin,  as  natural  remedies 
which  imitate  closely  the  principal  elements  of  the  gastric  juice, 
are  able  to  play  in  restoring  appetite,  the  power  to  digest  food, 
and  finally,  in  many  cases,  the  normal  secretion  of  that  juice 
itself. 

\Mien  the  mental  depression  is  verj^  marked,  and  the  condi- 


850  THE    GASTRO-IXTESTINAL    CLINIC 

tion  has  existed  so  long  that  complete  apathy  has  resulted,  the 
danger  to  life  is  considerable,  and  forced  feeding  through  a 
tube — gavage — is  sometimes  indispensable.  In  other  cases  the 
rest  cure  proves  a  most  valuable  means  of  restoring  the  normal 
state.  In  bad  cases  of  the  kind  it  is  frequently  quite  useless  to 
attempt  to  carry  out  a  successful  treatment  at  the  patient's 
home.  Treatment  in  some  institution,  or  seclusion  with  a 
skilled  nurse,  is  then  the  onlv  alternative. 


LECTURE  LXXVI 

THE    MOTOR    NEUROSES    OF   THE 
STOMACH^ 

Under  this  head  gastrologists  have  described  numerous  af- 
fections, the  predominant  feature  of  each  of  which  is  an 
abnormahty  of  some  one  or  more  of  the  motor  functions  of 
the  stomach.  These  inchide  the  fohowing:  irregular  or  over- 
persistent  contractions  (cramps  or  spasms)  either  of  the  gas- 
tric walls  as  a  whole,  or  of  the  sphincter  muscles  of  the  cardia 
or  pylorus,  and  insufficiency  of  the  same  with  such  direct  con- 
sequences of  insufficiency  of  the  cardia  as  rumination,  re- 
gurgitation, and  perhaps  some  of  the  forms  of  nervous  vomit- 
ing, as  well  as  nervous  belching,  pyrosis,  etc. ;  also  hypermo- 
tility  and  nervous  atony  or  hypomotility  and  hyperperistalsis 
(the  peristaltic  restlessness  of  Kussmaul). 

Spasm  of  the  Entire  Stomach  (Gastrospasm). — This  con- 
dition occurs  very  much  less  frequently  than  cramp  or  spasm 
of  the  orifices.  -  Indeed  it  is  exceedingly  rare.  It  may  result 
probably  from  hyperacidity  or  from  certain  derangements  in 
the  nen-ous  system  of  obscure  origin. 

The  symptoms  are  acute  crampy  pain,  and  often  a  visible 
contraction  of  the  stomach  into  a  hard  roundish  tumor. 

The  treatment  for  the  attack  should  be  hot,  wet,  and  emol- 
lient applications  locally,  such  as  a  hot  meal  poultice  or  wet 
compress,  with,  if  necessary,  morphine  or  atropine  or  both, 
hypodermically.  To  combat  the  tendency  employ  the  measures 
recommended  for  gastro-intestinal  neurasthenia,  under  the 
head  of  Nervous  Dyspepsia,  with  additionally  galvanism  or 
high-tension  faradism-  locally,  preferably  with  one  pole  within 

1  Some  of  the  motor  disturbances  of  the  stomach — notably  gastrospasm 
and  pylorospasm — are  accompanied  by  severe  pain,  and  therefore  may  be 
said  to  involve  both  sensory  and  motor  neuroses  ;  but  the  motor  fault  is 
here  the  primary  one. 


852  THE    GASTRO-INTESTINAL    CLINIC 

the  stomach.  The  pneumogastric  nerves  in  the  neck,  and  the 
second  to  the  fifth  dorsal  nerves,  should  also  be  stimulated 
mildly  at  their  origin  by  counter-irritation,  galvanism,  vibra- 
tion applied  by  a  mechanical  vibrator  or  otherwise.  (See  Lec- 
tures XXV.  and  XXVIII.) 

Spasm  of  the  Cardia. — This  is  a  spasmodic  contraction  of 
the  muscles  which  close  the  cardiac  orifice.  It  is  less  frequent 
than  spasm  of  the  pylorus.  It  may  be  provoked  by  the  intro- 
duction of  a  stomach  tube,  by  any  very  hot  or  cold  drinks,  or 
by  swallowing  unmasticated  morsels  of  hard  or  tough  food. 
Cardiospasm  may  also  result  from  overdistention  of  the 
stomach  with  swallowed  air,  or  with  gases  formed  within  the 
viscus,  the  pylorus  then  being  spasmodically  closed  at  the 
same  time;  or  from  the  irritation  of  an  ulcer  or  cancer  in  the 
immediate  vicinity  of  the  cardia,  wdiether  in  the  stomach  or 
lower  end  of  the  esophagus.  Gastric  hyperacidity  or  hyper- 
esthesia is  less  likely  to  be  an  efficient  cause  of  spasm  in  this 
part  of  the  stomach  than  in  the  pylorus.  Doubtless  cardio- 
spasm is  also  sometimes  a  consequence  of  a  nervous  shock, 
hysteria,  or  neurasthenia, — then  a  pure  neurosis. 

Acute  cardiospasm  of  purely  neurosal  origin  may  be  re- 
covered from  very  quickly,  or  may  last  a  day  or  two,  the  at- 
tacks recurring  meanwhile  every  time  an  attempt  is  made  to 
swallow.  When  it  depends  upon  some  lesion  in  the  vicinity  of 
the  cardia,  aggravated  by  hysteria  or  neurasthenia,  it  may  still 
possibly  be  controlled  by  appropriate  treatment,  but  is  likely 
then  to  be  much  more  stubborn.  The  chronic  neurosal  form, 
when  recent,  is  usually  curable,  but  the  longer  the  disease  has 
lasted,  the  less  amenable  it  is  to  treatment.  When  secondary 
to  some  other  disease,  the  prognosis  of  the  chronic  form  is 
that  of  the  primary  affection,  provided  it  be  treated  sufficiently 
early.  The  condition  sometimes  persists  for  years  and  then 
becomes  refractory,  as  a  rule,  to  all  therapeutic  measures. 

The  symptoms  of  acute  cardiospasm  are  occasional  attacks 
of  dysphagia — either  difficulty  in  swallowing  or  complete  in- 
ability to  swallow  from  a  spasm  of  the  sphincter — and  often  a 
regurgitation  of  food  before  it  has  entered  the  stomach.    The 


MOTOR    NEUROSES    OF    THE    STOMACH  853 

food  thus  brought  up  contains  neither  HCl  nor  peptones,  nor 
indeed  any  of  the  elements  of  the  gastric  juice  or  of  the  prod- 
ucts of  peptic  digestion.  The  attempt  to  pass  food  through  the 
orifice  usually  causes  severe  pain,  such  as  is  felt  in  cancer  of 
the  cardia,  but  in  some  chronic  cases  pain  is  wanting. 

Acute  spasm  of  the  cardia  is  most  likely  to  occur  in  nervous 
persons,  and  during  a  meal.  It  may  then  be  merely  transient, 
passing  oft"  in  a  few  minutes,  but  usually  recurs  frequently  in 
the  course  of  the  same  meal,  and  may  sometimes  be  persistent. 
In  the  more  chronic  form  swallowing  is  less  acutely  painful, 
but  it  may  be  impossible  to  get  any  except  liquid  food  into  the 
stomach,  and  in  the  worst  cases  not  even  liquids  will  pass,  ex- 
cept after  dilatation  with  a  sound  or  tube.  In  these  cases  feed- 
ing through  a  tube,  or  rectal  feeding,  may  need  to  be  resorted  to 
for  a  time.  The  stomach  then  becomes  much  contracted,  and 
it  is  generally  held  that  the  esophagus  becomes  dilated.  Riegel 
doubts  whether  dilatation  or  diverticulum  of  the  esophagus  is 
not  the  cause,  rather  than  a  consequence,  of  the  cardiospasm 
when  both  occur,  but  we  know  that  an  organic  stricture,  at  or 
above  the  cardia,  causes  a  pouching  in  the  esophagus,  and  it  is 
probable  that  persistent  spasmodic  stricture  may  have  a  like 
result. 

Tlic  diagnosis  of  cardiospasm  can  easily  be  made  from  a 
permanent  stricture  due  to  ulcer,  cancer,  or  other  cause,  by  in- 
troducing a  large-sized  tube  or  esophageal  sound.  This  will 
usually  pass  with  only  slight  difficulty,  encountering  only  a 
momentary  opposition,  when  the  closure  is  from  spasm,  but 
will  fail  entirely  to  go  through  an  organic  stricture.  Further 
trials,  then,  with  smaller  sizes  may  succeed.  In  the  latter  class 
of  cases  a  distinct  sensation  of  a  hard  obstruction  finally  over- 
come will  often  be  experienced  when  the  smaller  tube  or  sound 
passes  into  the  stomach,  though  when  a  very  small  tube  is 
used,  no  such  sensation  may  be  recognized. 

It  is  not  so  easy  to  distinguish  a  chronic  cardiospasm  from 
a  large  diverticulum  in  the  esophagus  with  a  consequent  dif- 
ficulty in  getting  food  or  a  tube  to  pass  into  the  stomach ;  but  by 


854  THE    GASTRO-IXTESTINAL    CLINIC 

a  patient  persistence  with  large-sized  tubes,  one  can  finally  be 
introduced  in  the  case  of  a  spasm,  after  first  encountering  a 
resistance  which  is  felt  to  yield,  while,  when  there  is  a  diver- 
ticulum, the  entering  is  purely  a  matter  of  luck ;  either  a  large  or 
small  tube  or  sound  will  sometimes  pass  in  easily,  and  at  other 
tipes,  being  caught  in  the  diverticulum,  cannot  possibly  be 
made  to  pass.  Then  in  the  spasmodic  cases,  even  when  chronic, 
there  are  nearly  always  occasional  times  when,  the  patient 
being  in  an  unusually  good  condition,  the  spasm  relaxes  and  all 
symptoms  cease  temporarily,  whereas,  when  there  is  a  divertic- 
ulum or  pouching  of  the  esophagus  or  any  organic  obstruc- 
tion, the  symptoms  never  abate,  but  rather  incline  to  become 
progressively  worse. 

■  You  should  bear  in  mind  especially  that  in  any  form  of  or- 
ganic disease  causing  obstruction  or  stenosis,  small  sounds  or 
tubes  can  be  introduced  more  readily  than  large  ones,  while, 
on  the  contrary,  when  a  spasm  of  the  cardia  causes  the  ob- 
struction, it  is  most  easily  overcome  by  the  largest-sized  in- 
struments. 

The  Treatment  of  Cardiospasm. — This  is  in  the  main  that 
of  neurasthenia,  which  has  been  mentioned  in  connection  with 
other  gastric  neuroses  and  fully  described  under  the  head  of 
Nervous  Dyspepsia.  Locally,  in  addition  there  should  be  a 
systematic  use  of  the  largest-sized  esophageal  sounds  or  firm 
stomach  tubes,  one  of  which  should  be  introduced  daily  and 
allowed  to  remain  in  position  for  ten  to  fifteen — some  say 
thirty — minutes  at  a  time.  When  there  is  a  coincident  gastric 
catarrh  and  much  fermentation,  the  thorough  washing  out  of 
the  stomach  daily  with  an  antiseptic  solution  will  prove  doubly 
curative,  provided  a  large  and  firm  tube  be  employed  for  the 
purpose.  Naturally  you  will  also  insist  upon  a  careful,  but 
nourishing  diet,  which  at  first  should  be  liquid  or  soft,  and 
upon  a  thorough  mastication  of  all  food.  Indeed,  a  solid 
or  semi-solid  food,  fully  liquefied  by  prolonged  mastication,  is 
better  than  liquids,  which  cannot  be  chewed.  When  the  spasm 
has  been  provoked  by  an  ulcer  or  erosions  near  the  cardia,  the 


MOTOR    NEUROSES    OF    THE    STOMACH  855 

frequent  passage  of  a  tube  or  sound  would  only  aggravate,  and 
it  is  then  necessary  to  pursue  the  treatment  suitable  for  the 
primary  affection,  including  rectal  feeding,  and  the  latter  is 
required  also  for  the  worst  cases  of  cardiospasm  dependent 
upon  some  neurosis. 

Einhorn  praises  large  doses  of  bromides  in  cardiospasm, 
and  suggests,  besides  the  remedial  measures  above  mentioned, 
that  in  the  chronic  cases  the  patient  after  every  meal  should 
make  a  special  effort,  by  an  extraordinary  pressing  action  long 
continued,  to  force  on  into  the  stomach  any  food  lodged  in  the 
esophagus,  and  th^t  every  evening  any  remains  of  food  left 
in  the  esophagus  should  be  washed  out  with  the  help  of  a 
tube. 

Spasm  of  the  Pylorus  (Pyloric  Cramp,  Pylorospasm). — 
This  is  probably  one  of  the  most  prevalent  and  most  pro- 
ductive of  injurious  consequences  of  all  the  reflex  and  nervous 
gastric  affections.  Pylorospasm  consists  of  a  spasmodic  con- 
traction of  the  circular  muscular  fibers  of  the  stomach  outlet, 
whereby  the  latter  is  kept  firmly  closed  for  much  longer  periods 
during  digestion  than  normal. 

The  commonest  cause  of  this  condition  when  it  is  not  due 
to  ulcer,  is  a  hyperacidity  of  the  stomach  contents,  usually 
an  excessive  secretion  of  HCl, — but  it  can  doubtless  be 
caused  by  an  undue  amount  of  the  organic  acids  which  result 
from  fermentation.  Possibly  the  ingestion  of  large  amounts 
of  sour  fruits,  tart  wines,  beer,  vinegar,  or  other  acid  food  or 
drink  may  have  a  like  effect  sometimes  in  neurasthenic  pa- 
tients. Large  pieces  of  tough  or  hard  and  indigestible  sub- 
stances, whether  ingested  as  food  or  otherwise,  are  probably  also 
capable  of  setting  up  a  pylorospasm  in  certain  nervous  persons, 
but,  as  a  rule  in  such  cases,  the  pylorus  relaxes  sufficiently  to 
let  the  digested  matter  pass  out,  while  the  undigested  pieces 
are  retained  often  for  long  periods,  as  shown  by  their  being 
brought  up  during  lavage,  days  or  even  weeks  after  they  were 
ingested.  The  seeds  and  skin  of  many  kinds  of  fruit,  and  the 
tough  pulp  of  oranges  especially,  are  often  detected  in  the  wash 


856  THE    GASTRO-INTESTINAL    CLINIC 

water  when  all  the  other  contents  of  the  stomach  had  passed  on 
into  the  duodenum.  In  time,  however,  even  such  tough  sub- 
stances, when  not  too  large,  will  usually  make  their  way 
through  the  pylorus,  which  doubtless  finally  relaxes  to  an  ex- 
ceptional extent  to  permit  their  passage,  except  when  there  is 
a  marked  tendency  to  pylorospasm. 

It  has  been  assumed  that  spasm  of  the  pylorus  may  some- 
times be  a  primary  disease  and  result  then  from  nervous  causes. 
This,  though  difficult  to  prove,  is  possible,  but,  if  it  exists  as  a 
primary  affection,  without  hyperacidity  or  other  reflex  cause, 
it  is  doubtless  extremely  rare. 

The  symptoms  of  pylorospasm  in  its  most  severe  form  are 
violent  and  painful  contractions  of  the  gastric  walls,  ending 
finally  in  vomiting;  except  when  there  is  a  coincident  spasm  of 
the  cardia,  closing  that  orifice  also.  In  case  of  the  latter  compli- 
cation the  pain  and  distention  of  the  stomach  become  very 
great,  and  it  is  then  necessary  either  to  empty, the  viscus  by 
introducing  a  tube,  or  else  to  administer  full  doses  of  some 
anodyne,  especially  morphine  and  atropine  hypodermically. 
But  such  extreme  cases  are  rare.  In  the  milder  ones  in  which 
the  pylorus  seems  to  remain  closed  for  several  hours  longer 
than  usual  after  each  meal,  the  symptoms  are  merely  an  un- 
pleasant feeling  of  weight  or  fullness  in  the  epigastrium  with 
generally  increased  fermentation  and  eructation  of  gases.  The 
excessive  fermentation  and  formation  of  large  amounts  of 
acetic,  butyric,  and  sometimes  also  of  lactic,  acid  may  irritate 
the  gastric  mucosa,  thus  adding  to  the  discomfort,  besides 
tending  to  the  development  of  chronic  catarrhal  inflammation, 
hypera^sthesia,  etc.  Moreover,  the  augmented  amounts  of  the 
organic  acids  doubtless  aggravate  the  pyloric  spasm,  and  thus 
a  vicious  circle  is  produced. 

The  worst  feature,  however,  of  the  affection  is  that,  when 
unrelieved,  it  almost  uniformly  causes  atony  of  the  gastric 
musculature  which  ultimately  develops  into  dilatation.  Most 
cases  of  so-called  atonic  dilatation  of  the  stomach  are  probably 
produced  in  just  this  way.     There  is  often  also  considerable 


MOTOR  NEUROSES  OF  THE  STOMACH  857 

tenderness  on  pressure  or  even  gentle  palpation  over  a  spas- 
modically contracted  pylorus. 

The  treatment  of  pylorospasm  is  for  the  most  part  that  of 
ulcer,  that  of  hyperchlorhydria  and  that  of  excessive  fermenta- 
tion and  organic  hyperacidity,  which  are  considered  in  the 
lectures  on  Sthenic  Gastritis,  Hyperchlorhydria,  Gastric 
Flatulency,  etc.  In  a  few  cases,  doubtless,  the  spasm  is  pri- 
mary and  merely  an  expression  of  the  neurotic  diathesis,  the 
real  disease  being  hysteria,  or  possibly  neurasthenia.  The 
treatment,  then,  must  be  that  required  for  the  underlying 
nervous  condition  and  should  include  the  various  strengthen- 
ing remedies  and  measures  to  which  I  have  so  often  referred. 

Peristaltic  Restlessness  (Hyperperistalsis). — Following 
Kussmaul,  authors  generally  describe  under  the  above  head  a 
symptom  denoting  a  disturbed  innervation  of  the  stomach. 
This,  when  severe  (which  is  rare),  may  occasion  a  patient 
much  annoyance.  It  is  simply  an  exaggeration  of  the  normal 
peristaltic  waves  or  rhythmic  contractions  of  the  stomach  walls 
which  pass  usually  every  few  seconds  from  the  cardia  to  the 
pylorus.  In  the  abnormally  excited  condition  these  waves, 
which  are  not  felt  in  health,  are  much  increased  in  force  and 
frequency,  insomuch  that  the  patient  is  conscious  of  them  and 
sometimes  much  disturbed  by  them.  At  times  they  are  re- 
versed in  direction — antiperistalsis. 

When  the  stomach  is  dilated  or  displaced  downward,  the 
contractions  are  plainly  visible  below  the  ribs  and  can  be  easily 
felt  upon  palpation.  The  affection  may  extend  beyond  the 
stomach,  involving  the  intestines  also.  The  contractions  often 
produce  a  loud  gurgling  noise  when  both  gases  and  liquid  are 
present  in  the  stomach. 

The  Causation  of  Peristaltic  Unrest. — It  is  held  by  some  that 
the  trouble  always  coexists  with  either  spasm  or  other  obstruc- 
tion of  the  pylorus  and  results  therefrom,  but  it  is  probable 
that  a  sufficiently  great  irritation  of  the  motor  nerves  of  the 
stomach  can  cause  hyperperistalsis  or  even  antiperistalsis  in 
the  absence  of  any  obstruction  at  the  outlet. 


858  THE   GASTRO-INTESTINAL    CLINIC 

Any  powerful  stimulation  of  the  gastric  mucosa  as  from 
hyperacidity,  overloading  of  the  stomach  with  food,  or  its  over- 
distention  with  gas,  tends  to  excite  the  affection  in  neurotic 
person?,  and  hypersesthesia  of  the  mucosa  further  conduces 
to  it.  But  pyloric  obstruction  is  certainly  a  strongly  pre- 
disposing cause,  if  it  be  not  an  indispensable  factor  in  the 
semiology. 

The  symptoms  have  already  been  described  above,  and  the 
affection  cannot  well  be  mistaken  for  any  other  when  the  stom- 
ach extends  below  the  ribs  so  that  the  contractions  can  be  seen 
and  felt.  In  the  rarer  cases  in  which  the  stomach  is  of  normal 
size  and  in  its  normal  position,  the  trouble  may  be  easily  over- 
looked, if  mild,  or  may  then  be  considered  as  a  form  of  nervous 
dyspepsia.  In  the  severer  forms,  even  though  the  viscus  does 
not  extend  below  the  ribs,  the  affection  should  be  suspected 
from  the  conjunction  of  the  peculiar  uncomfortable  sensa- 
tions, not  often  amounting  to  actual  acute  pain,  with  frequent 
loud  gurgling.  The  disease  is  then  also  likely  to  be  compli- 
cated by  excessive  eructations  and  even  vomiting.  Further- 
more, the  nutrition  will  suffer,  the  digestion  being  impaired  as 
in  most  excessive  aberrations  from  the  normal,  and  the  patient 
will  often  lose  so  much  in  weight  and  strength  as  to  awaken 
the  suspicion  of  malignant  disease. 

The  prognosis  is  good,  as  a  rule,  when  there  is  no  insuper- 
able obstruction  of  the  pylorus  or  other  organic  disease,  pro- 
vided the  patient  is  able  and  willing  to  persevere  with  the  neces- 
sary therapeutic  measures. 

The  treatment  demands  (i)  the  removal  of  any  existing 
cause  such  as  hyperacidity,  gastric  hypersesthesia,  overeating, 
insufficient  mastication,  or  any  curable  obstruction  of  the 
pylorus,  and  (2)  the  cure  of  the  underlying  nervous  condition 
by  the  methods  so  often  described  in  these  lectures.  Elec- 
tricity in  the  form  of  galvanism  to  the  spinal  centers,  and  to 
the  vagi  in  the  neck  with  the  positive  pole,  either  over  the  epi- 
gastrium or  within  the  stomach,  the  high-tension  faradic 
current   intragastrically   applied,   or   the   static   wave   current 


MOTOR    NEUROSES    OF    THE    STOMACH  859 

to  the  spine  and  epigastrium  alternately  is  the  most  efficient 
remedy. 

But  such  patients  need,  most  of  all,  to  live  hygienically  in 
every  way,  avoiding  all  excesses,  especially  sexual  irregulari- 
ties and  mental  overwork. 

Sedative  drugs,  such  as  the  bromides,  hyoscyamus,  etc.,  may 
be  temporarily  necessary,  and  the  nerve  and  blood  tonics  can 
usually  be  so  used  as  to  hasten  the  cure. 

Nervous  Eructation. — This  subject  is  considered  along  with 
the  other  types  of  eructation  in  Lecture  LXXIV.,  on  Excessive 
Eructation  and  Gastro-Intestinal  Flatulency  in  General.  Its 
importance  seems  to  me  to  have  been  somewhat  overrated  by 
writers  generally,  and  I  shall  not  take  up  further  space  with 
it  here. 

Nervous  and  Reflex  Vomiting, — The  complex  act  of  vomit- 
ing is  produced  by  a  peculiar  combination  of  muscular  move- 
ments, including  a  contraction  of  the  abdominal  muscles  and 
of  the  pylorus  as  well  as  of  the  gastric  walls,  and  a  relaxation 
of  the  cardia,  besides  a  shortening  and  widening  of  the  gullet 
and  a  shutting  off  of  the  windpipe  and  nares  by  the  action  of 
the  epiglottis  and  soft  palate.  It  occurs  as  a  symptom  of  va- 
rious diseases  of  the  stomach  and  intestines,  especially  of  ulcer 
and  carcinoma,  gastrectasis,  pylorospasm,  and  also  insufficiency 
of  the  cardia. 

Again  vomiting  occurs  reflexly  as  a  result  of  irritation  in 
various  remote  parts  of  the  body,  particularly  the  genital  or- 
gans, but  also  of  the  pharynx,  as  well  as  from  eye-strain, 
and  especially  from  inflammation  of  the  peritoneum.  When 
emesis  occurs  in  an  apparently  causeless  manner,  without  any 
lesion  near  or  remote  being  discoverable,  it  is  called  nervous 
vomiting.  In  hysteria  and  marked  neurasthenia  it  is  doubtless 
often  a  pure  neurosis,  the  result  of  an  irritation  in  the  nerve 
centers  or  nerves  themselves._  The  vomiting  of  the  gastric 
crises  in  locomotor  ataxia  is  usually  so  classed. 

Nervous  vomiting  in  certain  of  its  forms  is  believed  to  be 
due,  in  part  at  least,  to  insufficiency  of  the  cardia,  »and  possibly 


86o  THE    GASTRO-INTESTINAL    CLINIC 

in  most  cases  of  such  vomiting  a  relaxed  condition  of  the  car- 
dia  predisposes  to  it. 

Authors  describe  among  the  forms  of  nervous  vomiting 
what  is  called  juvenile  vomiting,  which  affects  especially  school 
children  as  an  alleged  result  of  overstudy,  but  more  likely  of 
eiye-strain  from  a  faulty  arrangement  of  their  desks  with  re- 
lation to  the  position  of  the  windows,  or  from  uncorrected 
ocular  faults.  This  form  of  the  affection  does  not  seem  to 
have  any  very  distinctive  symptoms.  It  may  be  known  only 
from  the  lack  of  other  cause,  and  is  remedied  by  taking  the 
children  out  of  school,  by  fitting  proper  glasses,  etc. 

Stockton,  the  American  editor  of  Riegel's  "  Diseases  of  the 
Stomach,"  refers,  in  a  note  under  Nervous  Vomiting,  to  the 
"  periodic  or  cyclic  vomiting  in  children,"  which  has  been  much 
discussed  by  pediatrists  in  this  country  during  the  past  ten 
years,  but  would  seem  to  be  a  different  disease  from  the  juvenile 
vomiting  described  by  German  and  American  gastrologists, 
since  it  appears  first  at  the  age  of  two  or  three  years.  It  is  a 
serious  affection  accompanied  by  great  prostration,  and  often 
proves  fatal. 

Periodic  vomiting  is  another  variety  which  has  been  de- 
scribed by  Leyden.  It  recurs  somewhat  regularly,  like  mi- 
graine, at  more  or  less  definite  intervals,  with  sometimes  head- 
ache, which  may  be  severe  and  from  no  discoverable  cause. 
This  may  possibly  be  merely  migraine  without  the  usual  in- 
tensity of  headache.  In  some  of  the  cases  there  are  constipation 
and  symptoms  of  indigestion  in  the  intervals,  but  as  a  rule  the 
patient  is  well  between  the  attacks.  These  may  last  a  few 
hours  only  or  several  days.  They  seem  to  require  the  usual 
treatment  of  migrainous  attacks,  to  wit:  rest,  pellets  of  ice, 
morphine,  belladonna,  etc.  As  in  the  case  of  that  disease,  too, 
there  does  not  appear  to  be  any  line  of  treatment  yet  tried  which 
will  surely  prevent  a  recurrence  of  the  attacks  in  all  cases.  Pos- 
sibly remedying  ocular  faults  or  other  causes  of  reflex  disturb- 
ance might  prove  more  successful. 

The  diagnosis  of  nervous  vomiting  can  only  be  made  by  ex- 


MOTOR    NEUROSES    OF    THE    STOMACH  86 1 

elusion — the  apparent  absence  of  any  sufficient  cause.  It  is 
generally  not  preceded  by  much  nausea  and  is  easy  in  character 
as  compared  with  that  dependent  upon  indigestion,  or  other 
real  gastro-intestinal  disease,  which  may  signify  that  there  is  a 
relaxed  or  easily  relaxable  cardia.  In  Leyden's  periodic  form, 
however,  there  is  often  nausea,  and  the  vomiting  may  be  very 
severe  and  difficult  to  control. 

When  the  patient  is  very  neurasthenic,  or  especiallv  if  hys- 
teric, attacks  of  apparently  causeless  vomiting  may  be  set  down 
as  neurotic,  when  a  thorough  examination  has  revealed  no 
lesion  in  the  eyes,  digestive  tract,  or  pelvis,  and  no  displace- 
ment of  the  kidneys  which  could  have  excited  it  reflexly.  In 
such  cases  some  of  the  dorsal  vertebrae — or  to  be  more  exact, 
the  intervertebral  spaces  on  one  or  the  other  side  of  the  spine — 
will  often  be  found  tender  on  pressure.  The  diagnosis  from 
gastroxynsis  is  made  by  determining  the  absence  of  any 
marked  excess  of  HCl. 

The  vomiting  not  only  occurs  usually  with  little  straining  or 
discomfort,  but  produces  very  little  depression.  The  patients 
continue,  as  a.  rule,  to  be  well  nourished  and  enjoy  compara- 
tively good  health.  Then,  too,  the  attacks  of  vomiting  are 
prone  to  follow  psychic  disturbances.  Sometimes  certain  kinds 
of  food  will  always  be  vomited  in  such  attacks,  while  other 
kinds  will  regularly  be  retained.  For  example,  solid  foods 
may  be  vomited  and  liquids  retained,  or  vice  versa. 

The  treatment  of  an  attack  of  nervous  vomiting  should  aim 
to  secure  rest  and  sedation.  The  patient  should  be  placed  at 
complete  rest,  preferably  in  bed,  and  hot,  moist  applications  be 
made  to  the  epigastrium.  In  some  severe  cases  sinapisms  or 
turpentine  stupes  may  accomplish  still  more.  The  best  results 
will  follow  the  withdrawal  of  all  food  by  the  mouth,  and  feed- 
ing, if  necessary,  by  the  rectum,  though  very  small  quantities 
of  bland  liquid  food  may  be  tolerated  in  the  milder  cases.  The 
following  mixture  will  usually  prove  effective  if  any  medicine 
should  be  required  in  addition  to  the  measures  just  men- 
tioned : 


862  THE    GASTRO-INTESTINAL    CLINIC 

i^     Bismuthi  subuit 3  i 

Cerii  oxalat 3  ss 

Glycerit.  ac.  carbol.  (1-4) 7;z  xx 

Sps.  chloroformi      ,  ^^ ^  ^  .^^ 

Tr.  cardomon.   co.  f 

Aquae  menth.  pip ^ f  3  iv 

Aquse  calcis q.  s.  ad  f  3  ii 

M.  Sig.     Teaspoonful  in  a  tablespoonful  of  water  every  hour  till 
relieved. 

Between  the  attacks,  your  efforts  should  be  directed  to  the 
general  condition,  and  to  an  improvement  of  the  nerve  supply 
of  the  stomach  as  well  as  of  the  nervous  system  in  general.  A 
particularly  efficacious  method  of  accomplishing  these  objects 
is  the  application  of  galvanism  3  to  15  ma. — with  the  negative 
pole  stabile  over  the  epigastrium,  in  the  form  of  a  flat  electrode 
about  four  to  five  inches  square,  and  the  positive  as  a  small 
sponge  electrode  passed  over  the  tender  region  alongside  the 
spine  for  from  five  to  ten  minutes  ever}^  other  day.  A  current 
of  2  to  5  ma.  should  also  be  applied  to  the  vagi  in  the  neck  for 
two  or  three  minutes  at  each  seance.  Static  sparks  over  the 
epigastrium  and  the  static  breeze  or  wave  current  over  the 
spine  will  often  do  as  well  or  better;  and  very  brief  applica- 
tions with  a  good  rigid  mechanical  vibrator,  over  the  same  re- 
gions, will  also  prove  helpful. 

In  all  difficult  or  stubborn  cases,  a  thorough  search  should 
be  made  for  some  direct  or  reflex  cause  of  the  trouble.  An 
examination  should  be  made  of  the  pelvic  organs,  for  movable 
kidney  or  other  ptosis,  and  for  a  swelling  in  the  region 
of  the  appendix.  Not  to  discover  an  existing  lesion  in  any 
of  these  regions,  which  had  excited  the  vomiting,  would  be 
to  meet  with  failure.  You  would  naturally  examine  also  the 
vomited  matter  to  see  that  it  did  not  contain  an  excess  of 
HCl,  pointing  to  a  possible  ulcer,  gastroxynsis,  Reichmann's 
disease,  or  even  a  simple  hyperchlorhydria,  any  one  of  which 
might  give  rise  to  severe  vomiting;  and  look  carefully  in  the 
ejecta  for  l)k)0(l  or  changed  blood,  which  might  have  come 
from  a  latent  ulcer  or  carcinoma.  The  finding  of  any  of  these 
things  would  lead  you  to  shape  your  treatment  accordingly, 


MOTOR    NEUROSES    OF    THE    STOMACH  863 

and  not  only  to  direct  your  remedial  measures  more  success- 
fully, but  also  enable  you  to  give  a  more  accurate  prognosis. 

Treatment  of  Reflex  Vomiting — Pernicious  Vomiting  of 
Pregnancy. — In  the  treatment  of  these  forms  of  vomiting, 
it  goes  without  saying  that  the  main  thing  is  to  remove 
the  cause — cure  the  primary  affection.  To  take  up  all 
the  possible  diseases  and  special  conditions  which  can  cause 
reflex  vomiting,  and  consider  the  treatment  suitable  to  each, 
would  far  transcend  the  limits  of  these  lectures.  In  the  case  of 
one  of  them,  however, — the  pernicious  vomiting  of  pregnancy, — 
some  consideration  of  the  most  approved  remedial  measures  is* 
desirable,  since  it  is  a  serious  complication  which  quite  un- 
necessarily destroys  many  valuable  lives. 

Systematic  lavage  has  cured  numerous  cases  of  this  affec- 
tion, but  probably  those  only  which  were  dependent  in  part 
upon  chronic  gastric  catarrh  or  dilatation  with  excessive  fer- 
mentation. Treatment  addressed  to  the  nerv^es  supplying  the 
stomach,  and  measures  designed  to  lessen  the  reflex  irritation 
near  its  source,  have  occasionally  proved  successful.  For 
strengthening  the  gastric  nerves  the  mode  of  applying  elec- 
tricity to  the  spine,  epig'astrium,  and  vagi  in  the  neck,  already 
described  above  .as  useful  in  nervous  vomiting  generally,  prom- 
ises most.  Hot,  moist  applications,  or  even  blisters  over  the 
epigastrium,  often  afford  relief. 

The  local  treatment  should  consist  first  in  correcting  any  ex- 
isting displacement  or  other  fault.  Next  after  this,  the  most 
effective  in  lessening  or  diverting  into  other  channels  the  re- 
flex irritation  has  been  some  decided  revulsive  application  to 
the  OS  uteri,  and  Hirst^  reports  that  sometimes  he  has  found 
a  simple  vaginal  examination  sufficient  to  check  the  vom- 
iting. Usually  a  powerful  impression  must  be  made  upon  the 
uterine  nerves  to  prove  curative.  An  application  of  Churchill's 
tincture  of  iodine  will  sometimes  succeed,  but  a  surer  means 
is  one  long  used  successfully  by  Dr.  Jacob  Price  of  West 
Chester,  Pa.  It  consists  of  the  old-fashioned  method  of 
'  "  Text-book  of  Obstetrics,"  Saunders  &  Co.,  Philadelphia,  1903. 


864  THE    GASTRO-INTESTINAL    CLINIC 

cauterizing  the  os  uteri  externally  with  nitrate  of  silver  in 
stick  form.  When  this  fails,  a  cautious  dilatation  of  the  cervix 
uteri,  under  strict  aseptic  precautions,  with  a  series  of  gradu- 
ated bougies,  will  occasionally  stop  the  vomiting  without  bring- 
ing on  premature  labor. 

Edgar  reports  that  he  has  "  dilated  the  internal  os  in  primi- 
gravidse,  curetted  the  cervical  canal,  scraped  the  cervix  itself 
free  from  erosions,  applied  pure  carbolic  acid  to  the  cervix  and 
canal,  and  obtained  a  cure  without  interrupting  pregnancy  in 
a  number  of  cases  given  up  as  hopeless  and  sent  to  the  hospital 
to  have  labor  induced."  He  adds  that  "  the  finger  will  oc- 
casionally serve  as  a  dilator,  and  in  early  cases  the  greatest 
care  must  be  used  not  to  rupture  the  membranes."^ 

But  such  measures  should  be  resorted  to  only  after  a  con- 
sultation with  another  physician,  so  that  if  they  should  fail  to 
accomplish  their  intended  object,  and  labor  should  result,  the 
latter  could  be  accepted  and  welcomed  as  the  proper  alternative. 

When  other  means  are  ineffective,  the  uterus  should  be 
emptied  as  promptly  as  possible.  I  have  seen  very  precious 
lives  sacrificed  by  delaying  too  long  to  obey  this  imperative  in- 
dication, when  other  measures  had  failed  to  stop  the  vomiting 
within  a  reasonable  time.  The  patient's  vitality  finally  became 
exhausted  before  the  operation  was  attempted.  The  induc- 
tion of  premature  labor  promises  little  or  nothing  to  an  ex- 
hausted woman,  but  to  rescue  her,  must  be  done  while  she 
still  has  a  good  degree  of  strength. 

In  very  aggravated  cases,  not  more  than  two  weeks  at  the 
most  should  be  spent  in  experimeiiting  with  palliative  or  con- 
servative remedies,  and,  meanwhile,  nutrition  should  be  main- 
tained by  means  of  rectal  feeding.  In  less  serious  cases  in 
which  the  flesh  and  strength  are  being  but  slightly  lowered,  it 
may  be  safe  to  wait  until  the  end  of  the  third  month,  when,  as 
a  rule,  the  vomiting  tends  to  cease  of  itself.  If  after  that,  two 
weeks  of  further  treatment  have  effected  no  progress  toward 
a  cure,  labor  should  be  purposely  brought  on  and  the  uterus 
1  "  The  Practice  of  Obstetrics,"  Blakiston's  Son  &  Co.,  1903. 


MOTOR    NEUROSES    OF    THE    STOMACH  865 

emptied,  provided  dilatation  of  the  cervix  fails  to  bring  relief 
or  of  itself  set  up  uterine  action. 

In  all  severe  cases  the  patient  should  be  kept  in  bed,  sexual 
intercourse  prohibited,  and  her  strength  spared  in  all  possible 
ways. 

Drugs  usually  fail  to  help  much,  but  the  prescription  for  a 
sedative  mixture  which  I  have  given  in  the  former  part  of  this 
lecture  for  the  treatment  of  nervous  vomiting  generally,  may 
sometimes  succeed,  as  will  occasionally  i-io-grn.  doses  of 
calomel  given  every  hour  or  two  till  purgation  results.  Bro- 
mides, opiates,  or  hyoscyamus  by  suppository,  or  hypoder- 
mically,  occasionally  assist  in  controlling  the  vomiting. 

But  let  me  repeat  that,  in  many  of  the  more  serious  cases,  to 
empty  the  uterus  offers  the  only  hope,  and  this  must  not  be 
postponed  too  long. 

Nervous  Atony  of  the  Stomach. — This  is  sufficiently  dis- 
cussed in  Lecture  XXXVI.  under  the  head  of  Gastric  Atony  or 
Myasthenia  Gastrica,  etc.  The.  various^  forms  of  atony,  both 
neurosal  and  otherwise,  are  therein  considered  at  much  length. 
The  subject  is  again  referred  to  in  this,  connection,  for  the 
reason  that,  most  authors  class  Gastric  Atony  among  the  neu- 
roses of  the  stomach.  I  think,  however,  it  has  been  shown  in 
the  lecture  above  mentioned  to  be  predominantly  a  result  of 
either  local  inflammatory  or  mechanical  conditions,  or  depraved 
constitutional  states  in  which  the  weakening  of  the  gastric 
musculature  has  been  produced  by  a  generally  lowered  nutri- 
tion, including  usually  impoverished  blood. 

But  the  affection  is-  doubtless  sometimes-  encountered  as  a 
consequence  of  psychic  influences  coming  on  more  or  less  sud- 
denly during  apparent  health.  When  it  thus  occurs,  the  ab- 
sence of  any  of  the  more  usual  aetiologic  factors  and  the  history 
of  a  shock  or  other  nervous  disturbance  should  enable  you  to 
differentiate  it. 

The  treatment  would  then  consist  of  a  removal  of  such  cause 
or  the  combating  by  appropriate  measures  of  any  depressing 
influence,  and  at  the  same  time  fortifying  the  nearly  always 


866  THE    GASTRO-IXTESTIXAL    CLIXIC 

excessively  vulnerable  nervous  system.  Persons  encloved  with 
a  strong  constitution  and  sound  nerves  are  not  likely  to  have 
their  stomachs  seriously  give  out  from  any  mental,  nervous, 
or  emotional  disturbance. 

Insufficiency  of  the  Cardia,  Rumination,  Regurgitation,  etc. 
— It  is  convenient  to  assume,  as  most  authors  do,  that  there 
may  be  a  sort  of  paresis  of  the  cardia.  The  habit  of  rumina- 
tion— that  is,  the  frequent  raising  without  nausea  of  ingesta 
from  the  stomach  into  the  mouth,  then  chewing  them  further 
and  swallowing  them  again, — or  the  vers*  similar  habit  of 
bringing  up  without  effort  or  nausea  food  previously  swal- 
lowed, and  actually  ejecting  it — regurgitation — are  generally 
considered  to  result  from  an  aljnormally  relaxed  state  of  the 
circular  muscle  which  forms  the  sphincter  of  the  cardia.  In- 
ordinate belching  and  very  frequent  as  well  as  quite  easy  vom- 
iting are  often  attributed  to  the  same  defect.  There  is  no  ab- 
solute proof,  however,  that  these  symptoms  result  from  any 
such  cause,  though  rumination  has  been  observed  in  a  case 
afterward  shown,  at  autopsy,  to  have  been  one  of  carcinoma  of 
the  gastric  walls,  including  the  cardia,  wliich  was  abnormally 
wide,  while  there  was  also  cylindric  dilatation  of  the  esophagus. 

Another  theory  as  to  the  causation  of  such  symptoms  is 
that  they  are  due  to  an  irritated  state  of  the  vagus  and  over- 
stimulation of  the  dilator  nerve  of  the  cardia. 

!Much  has  been  written  concerning  regurgitation  and  ru- 
mination, or  mer3xism,  but  when  it  is  carefully  sifted,  only  a 
few  grains  of  actual  reliable  information  about  these  habits 
remain.  Owing  to  the  absence  of  effort  or  disturbance  asso- 
ciated with  the  acts,  the  prevalent  belief,  that  a  lack  of  tone  in 
the  sphincter  muscle  of  the  cardia  is  at  least  a  contributory 
cause,  is  probably  well  founded.  But  extensive  obsen-ations 
by  numerous  careful  investigators  prove  that  neither  excessive 
nor  deficient  motility  nor  excessive  nor  deficient  gastric  secre- 
tion plays  any  part  in  the  ?etiolog}\ 

Rumination  has  been  shown  to  result  from  imitation  in  sev- 
eral instances,   and  1x)th   habits  are  most   frequently  seen   in 


MOTOR    NEUROSES    OF    THE    STOMACH  86/ 

hysteric  or  neurasthenic  persons.  Insanity,  imbecihty,  and  epi- 
lepsy still  more  strongly  predispose  to  them.  Rapid  and  ex- 
cessive eating  and  imperfect  mastication  may  unquestionably 
prove  efficient  as  predisposing  causes.  Gastritis  and  other  le- 
sions of  the  stomach  are  believed  sometimes  to  produce  the 
affections. 

Tlie  treafjiieiit  of  regurgitation  and  rnniiiiatioii  will  prove 
successful  in  most  cases  if  faithfully  persevered  with,  and  if  the 
patients  have  sufficient  will-power  to  do  their  part.  They  must 
be  taught  to  chew  all  food  until  it  is  either  liquefied  or  pulp- 
efied,  and  energetically  oppose  with  a  strong  effort  of  the  will 
any  tendency  to  let  any  of  it  come  up.  When  the  habit  has 
been  to  eject  the  regurgitated  material,  the  first  step  must  be 
to  retain  it  in  the  mouth,  when  the  impulse  to  raise  it  cannot  be 
at  once  controlled,  and  then,  after  further  chewing,  to  swallow 
it  again.  This  converts  regurgitation  into  rumination.  Then, 
by  the  utmost  possible  exertion  of  will-power,  aided  by  the  im- 
perative commands  of  the  physician,  the  latter  practice  may 
often  be  finally  overcome,  even  without  other  treatment.  But 
all  the  oft-advised  therapeutic  methods  useful  for  neurasthenia, 
including  cold  sponge  baths,  regulated  exercises,  outdoor  life, 
and  especially  electricity,  may  be  employed  with  advantage  as 
adjuvants  to  the  cure.  Galvanism  or  high-tension  faradism, 
externally  or  within  the  stomach,  will  be  found  generally  useful, 
and  the  static  spark,  applied  to  the  region  of  the  cardia,  should 
prove  especially  effective.  Full  doses  of  strychnine  have  also 
been  highly  praised  for  their  curative  action  in  these  affections. 
In  all  the  more  stubborn  cases,  at  least,  you  should  test  the 
stomach  contents  and  combat  with  appropriate  remedies  any 
excess  or  deficiency  of  HCl.  Observations  upon  one  ruminant 
showed  hyperchlorhydria,  and  he  was  then  quite  rapidly  cured 
by  the  administration  of  alkalies.  This  led  to  the  theory  that 
rumination  depended  upon  hyperacidity  and  could  be  cured  by 
alkaline  treatment.  But  another  obsenxr  disproved  this  theory 
when  he  reported  a  series  of  cases  showing  a  deficiency  of  HCl, 
and  responding  well  to  HCl  given  as  a  remedy. 


868  THE  gastro-intEstinal  clinic 

Insufficiency  of  the  Pylorus. — It  is  well  known  that  the 
pylorus  may  lose  its  power  of  closing  tightly  and  remain  un- 
duly patulous  as  a  result  of  certain  mechanical  causes.  Among 
these  is  carcinoma  or  ulcer  of  the  part  acting  through  a 
process  of  infiltration  of  the  circular  muscular  fibers  of  the 
pylorus,  as  a  result  of  which  the  latter  are  permanently  stiff- 
ened— rendered  incapable  of  efficient  contraction.  Obstruction 
of  the  duodenum  by  a  stricture  from  any  cause  (as  carcinoma, 
round  or  peptic  ulcer,  or  syphilitic,  tuberculous,  or  simple  catar- 
rhal ulceration),  or  by  the  closing  of  its  lumen  from  the  press- 
ure of  a  tumor,  or  a  movable  kidney,  etc.,  may  produce  a  like 
condition. 

Since  Ebstein  demonstrated  a  relaxation  of  the  pylorus  as 
a  consequence  of  pressure  myelitis,  authors  have  generally  as- 
sumed the  possibility  of,  and  described  a  nervous  insufficiency 
of  the  pylorus.  Riegel,  however,  has  never  encountered  any 
case  of  the  kind,  and  a  number  of  prominent  gastrologists  seem 
to  lack  personal  experience  with  such  a  condition.  Injury  of 
the  portion  of  the  cord  whence  emerge  the  motor  nerves  that 
supply  the  sphincter  muscle  of  the  pylorus  may  doubtless  para- 
lyze it,  but  such  an  injury  must  be  rare,  and  the  possibility  of 
it  by  no  means  warrants  us  in  assuming  a  neurotic  incontinence 
of  the  pylorus  comparable  to  the  neuroses  which  are  familiar 
phenomena  of  hysteria  or  neurasthenia.  Ebstein' s  case  was 
no  doubt  a  true  paralysis  of  the  pyloric  sphincter,  and  in  no 
proper  sense  a  neurosis,  ^^'hen  pyloric  incontinence  exists  in 
the  absence  of  any  mechanical  cause  for  it,  the  more  plausible 
explanation  seems  to  be  the  one  championed  by  Knapp,  viz., 
that  the  muscle  has  become  exhausted  by  long  overaction. 

Other  cases  of  apparent  pyloric  insufficiency,  in  which  no 
lesion  could  be  discovered  in  either  the  pylorus  itself  or  in  the 
duodenum,  have  been  reported  by  Ebstein,  and  there  is  no 
doubt  that  such  cases  do  occur.  Ewald  says  on  this  head : 
"  Unfortunately  we  have  no  diagnostic  criteria  by  which  we 
may  establish  the  existence  of  this  condition  as  dependent 
upon  atony  of  the  pyloric  sphincter — /.  e.,  a  pure  neurosis — 


MOTOR    NEUROSES    OF    THE    STOMACH  869 

for  an  occasional  incontinence  of  the  pylorus  is  a  normal  phe- 
nomenon."^ 

The  symptoms  of  pyloric  insufficiency  are  abnormally  rapid 
emptying  of  the  stomach,  a  difficulty  in  inflating  it  with  air  or 
CO2,  and  the  frequent  finding  of  bile  in  the  wash  water  during 
lavage.  The  first  symptom  has  been  commonly  explained  as 
due  to  hypermotility  or  overexcitation  of  the  gastric  peristaltic 
apparatus,  but  I  am  now  convinced  that  atony  of  the  pylorus 
may  also  cause  it. 

Diarrhea  following  immediately  after  the  ingestion  of  very 
hot  or  cold  or  insufficiently  masticated  pieces  of  hard  or  tough 
food  might  be  due  to  pyloric  incontinence,  but  would  not  alone 
be  conclusive. 

The  one  sure  means  of  demonstrating  the  sufficiency  of  the 
pylorus  is  by  intubating  it  according  to  the  Hemmeter  method 
with  one  of  the  ingenious  instruments  devised  by  Hemmeter 
and  Turck  in  this  country  and  F.  Kuhn  of  Giessen.  With  re- 
gard to  the  question  of  priority,  it  may  now  be  regarded  as 
settled  that  both  Hemmeter  and  Turck  in  this  country  intubated 
the  duodenum  through  the  pylorus  before  the  procedure  was  at- 
tempted by  Kuhn. 

Knapp^  insists  that  insufficiency  of  the  pylorus  is  quite  fre- 
quent, and  that  it  is  the  natural  result  of  a  prolonged  condi- 
tion of  hypertonicity  of  the  part,  the  overtaxed  muscle  finally 
becoming  exhausted  and  weak.  He  maintains  that  delayed 
emptying  of  the  stomach  is  generally  due  rather  to  an  over- 
vigorous  contraction  of  the  pylorus  (pylorospasm)  than  to 
atony  of  the  gastric  muscle  (which  is  doubtless  often  true  of 
the  earlier  stages  of  prolonged  retention  of  food  in  the  stom- 
ach), and  conversely  that  a  too  rapid  emptying  of  the  stomach 
is  evidence  rather  of  an  exhausted  and  relaxed  pylorus,  than  of 
hypermotility  of  the  gastric  walls.  From  this  point  of  view, 
the  symptoms  of  pyloric  insufficiency,  beside  the  reflux  of  bile 
or  other  duodenal  contents  into  the  stomach,  are  the  failure 

1  "  Diseases  of  the  Stomach,"  New  York,  1892. 
"^  Jour.  Am.  Med.  Assn.,  April  16,  1904. 


8/0  THE    GASTRO-IXTESTIXAL    CLINIC 

to  find  any  gastric  contents  or  the  usual  quantity  of  them  at 
the  end  of  an  hour  after  the  test  breakfast,  and  it  would  fol- 
low further  that  most  of  the  symptoms  of  intestinal  indiges- 
tion, such  as  flatulency,  pains  in  the  bowels,  constipation,  or 
diarrhea,  may  be  produced  or  aggravated  by  pyloric  inconti- 
nence from  any  cause. 

The  treatment  of  pyloric  insufficiency  in  not  too  old  patients 
may  be  hopefully  undertaken  when  there  is  no  organic  lesion 
in  the  part  or  serious  chronic  debilitating  disease  elsewhere  in 
the  body.  The  more  fermentable  foods  and  drinks,  ef- 
fervescent beverages,  and  also,  generally,  coffee  and  tea  must 
be  avoided.  Thorough  mastication  of  all  food  is  particularly 
important.  Combinations  of  an  alkali  with  bitter  tonics  are 
often  helpful.  Nearly  all  authorities  agree  in  recommending 
strychnine  in  full  doses,  though  some  recent  experiments  throw 
doubt  upon  the  prevalent  view  that  strychnine  strengthens 
muscular  fibers.  Electricity  is  praised  by  those  who  have  had 
most  experience  with  it.  The  faradic  current  applied  in- 
tragastrically  will  prove  the  most  efficient  form  of  administer- 
ing it.  Static  sparks  taken  directly  from  the  pyloric  region  are 
capable  of  powerfully  stimulating  the  weakened  muscle.  Mas- 
sage of  the  abdomen,  vibratory  stimulation,  and  cold  affusions 
to  the  part  are  also  useful. 


LECTURE  LXXVII 

NERVOUS    DYSPEPSIA   (GASTRO-INTES- 
TINAL    NEURASTHENIA) 

The  conceptions  of  nervous  dyspepsia  have  been  almost  as 
various  as  the  authors  who  have  written  upon  it,  and  the  ail- 
ments which  are  given  this  name  by  physicians  in  practice  are 
very  often  something  else — direct  or  indirect  results  of  patho- 
logic changes,  such  as  the  inflammatory  affections,  muscular 
insufhciency,  dilatation  or  displacement  of  the  stomach,  dis- 
placement of  one  or  both  kidneys,  disease  of  the  pelvic  organs, 
or  disease  or  disorder  of  some  kind  in  the  intestines. 

In  a  large  proportion  of  the  cases  of  so-called  nervous 
dyspepsia,  the  trouble  is  dependent  upon  actual  disease  some- 
where in  the  gastro-intestinal  tract,  though  very  often  such 
cause  is  unrecognized  and,  It  may  be,  unrecognizable. 

The  mythologic  deities  of  antiquity  have  all  disappeared  as 
scientific  causes  have  been  discovered  for  phenomena  previously 
considered  supernatural,  and  in  like  manner  nervous  dyspepsia 
may  ultimately  cease  to  be  classed  as  a  distinct  type  of  disease 
when  our  methods  of  diagnosis  shall  have  become  more  perfect. 
The  fewest  cases  of  it  are  encountered  now  by  the  men  who  are 
the  most  expert  and  painstaking  in  their  examinations. 

There  is  no  apparent  appropriateness  in  giving  this  designa- 
tion to  any  gastric  derangements  or  symptoms  that  result  from 
organic  changes  in  other  organs,  as  the  heart,  lungs,  kidneys, 
or  even  In  the  central  nervous  system.  Thus  the  gastric  crises 
of  tabes  surely  should  not  be  called  nervous  dyspepsia  any  more 
than  the  vomiting  of  Bright's  disease  or  of  strangulated  hernia. 
Possibly  there  may  be  some  reason,  however,  for  considering 
under  this  head  the  frequent  gastric  symptoms  of  hysteria. 
The  symptoms  resulting  from  abnormalities  of  secretion  by  the 

871 


872  THE    GASTRO-INTESTINAL    CLINIC 

gastric  glands  are  classed  by  some  writers  under  nervous  dys- 
pepsia, but  I  prefer  to  limit  the  term  strictly  to  forms  of  indi- 
gestion or  gastric  symptoms  which  cannot  be  traced  to  any 
organic  lesion,  and  are  not  the  manifest  result  of  even  any 
well-known  so-called  functional  affection. 

In  general  neurasthenia  it  is  usual  to  find  the  digestion  more 
or  less  impaired,  and  most  frecjuently  then  there  is  either  1 
variable  secretion  or  sometimes  a  rather  persistent  increase  or 
diminution  of  the  gastric  juice,  to  which  the  discomforts  pres- 
ent may  be  attributed.  Then,  again,  however,  you  will  see 
cases  in  which  the  neurasthenia  will  seemingly  be  limited  to 
the  stomach  and  intestines,  no  complaints  being  made  of  any 
function  except  those  of  digestion  and  defecation.  You  may 
be  unable  to  discover  a  lesion  of  any  kind  in  any  of  the  organs. 

It  is  convenient  at  present  to  retain  the  name  nervous  dyspep- 
sia for  these  as  well  as  possibly  for  the  type  of  indigestion  oc- 
curring In  the  course  of  that  form  of  general  neurasthenia  in 
which  mental  depression,  and  a  marked  delicacy  or  sensitive- 
ness of  the  nervous  system,  with  a  great  variability  of  symp- 
toms, exist  without  any  discoverable  dependence  upon  disease 
having  its  origin  in  the  intestines,  liver,  or  elsewhere  in  the 
digestive  system.  The  term,  then,  shall  be  limited  here  to  the 
apparently  causeless  dyspepsias,  and  experience  shows  that 
these  are  found  usually  associated  with  neurasthenia. 

Symptomatology. — Any  form  or  shade  of  pain  or  unpleasant 
sensation  referable  to  the  stomach  or  intestines  may  be  com- 
plained of.  Nausea,  vomiting,  gaseous  distention,  sensations 
of  dragging,  fullness  or  weight  (though  these  last  generally  in- 
dicate motor  insufficiency  or  a  demonstrable  weakness  of  .the 
stomach  walls),  heaviness,  drowsiness,  dizziness,  prostration 
or  languor,  flatulency,  headache,  or  mental  irritability  during 
the  digestive  period,  may  be  present  in  nervous  dyspepsia.  In 
short,  it  may  mimic  almost  any  of  the  symptoms  of  gastric 
disease,  or  many  of  those  usually  seen  in  intestinal  disorders. 
The  discomfort  occurs,  as  a  rule,  during  the  digestive  period 
only,  and  the  patient  generally  feels  well  when  the  stomach  is 


NERVOUS    DYSPEPSIA  873 

empty.  The  ganglia  presiding  over  the  nerves  of  the  stomach 
may  be  presumed  to  be  at  fault  in  some  v^ay  in  these  cases. 
Ewald  refers  to  the  investigations  by  Jiirgens'  on  the  bodies  of 
forty-one  patients  who  had  complained  of  vague  dyspeptic  dis- 
turbances during  life,  showing  a  complete  degeneration  of 
Meissner's  and  Auerbach's  plexuses.  However  this  may  be, 
the  innervation  of  the  gastric  structures  is  faulty;  and  just  as 
in  general  neurasthenia  there  is  an  excessive  impressionability 
and  an  undue  response  to  all  stimuli,  so  in  gastric  neurasthenia 
there  may  be  an  excessive  secretion  of  the  gastric  juice  after 
taking  food  (especially  meat  or  acids),  or  a  depression  of  such 
secretion  below  the  normal  with  an  absence  of  free  HCl,  if  the 
patient  chance  to  drink  a  pint  of  some  alkaline  table  water  or  to 
be  taking  an  alkali  or  belladonna  as  a  medicine.  But  when  the 
aberration  of  secretion  is  marked  enough  to  have  set  up  a  de- 
cided and  persistent  hyperchlorhydria,  the  case  could  no  longer 
be  properly  designated  as  one  of  mere  nervous  dyspepsia. 
Then,  any  of  the  symptoms  of  general  neurasthenia  may  be 
present,  such  as  mental  depression,  insomnia,  special  fears,  as 
of  crowds,  closed  places,  elevators,  etc.,  and  greatly  increased 
impressionability. 

One  symptom-  of  importance  that  is  considered  characteristic 
by  most  authors  is  a  lack  of  relation  between  the  amount  of 
indigestion  and  the  quality  of  the  food  taken.  For  instance,  the 
true  nervous  dyspeptic  will  often  complain  as  much  after  eating 
bread  and  butter  or  plain  beefsteak  as  after  a  complicated  mixed 
meal  including  shell-fish  or  mince  pie.  But  there  are  apparent 
exceptions  to  this  statement.  Notwithstanding  the  fact  that 
with  them  one  food  is  digested  about  as  well  as  another  and 
produces  usually  the  same  amount  of  discomfort,  gastric  neu- 
rasthenics are  prone  to  fancy  great  dififerences  and  to  deny 
themselves  one  class  of  foods  after  another,  until  at  last  they 
attain  a  condition  of  subnutrition  which  amounts  to  semi-star- 
vation and  seriously  aggravates  their  disorder.  When  given  a 
diet  table  they  readily  abstain  from  the  articles  forbidden,  but 

'  Jurgens,   Ver handlungen  des  III,  Congress  f.  inner e  Medecin,  S.,  S^S- 


8/4  THE     GASTRO-INTESTINAL    CLINIC 

neglect  to  make  up  the  deficiency  from  the  allowed  list,  and  the 
observant  physician  soon  finds  them  losing  flesh  faster  than 
before,  merely  from  a  lack  of  sufficient  food. 

Numerous  intestinal  symptoms  and  diseased  conditions  have 
been  described  as  frequently  accompanying  nervous  dyspepsia. 
These  may  include  constipation,  diarrhea,  gaseous  distention, 
either  general  or  partial  (spastic  phenomena),  tender  areas 
over  the  colon  especially,  membranous  colitis,  etc.  These  phe- 
nomena are  indeed  exceedingly  common  in  association  with 
neurasthenia,  both  gastric  and  general,  but  in  many  cases  are 
probably  the  cause  rather  than  result  of  the  nervous  condition, 
or  if  an  inherited  nervous  dyscrasia  was  the  first  link  in  the 
chain,  a  vicious  circle  has  been  formed,  and  the  two  conditions 
act  and  react  upon  each  other  in  an  injurious  manner. 

The  skin  over  the  stomach  may  be  unduly  sensitive,  both 
before  and  behind,  and  on  either  side  of  the  spine  correspond- 
ing to  the  origin  of  the  nerves  supplying  the  stomach.  Espe- 
cially over  the  ganglia  of  the  great  sympathetic  system,  deep 
pressure  will  be  likely  to  cause  pain. 

Diagnosis. — This  calls  for  the  most  thorough  examination 
of  the  entire  body,  including  the  secretions,  excretions,  and  the 
blood,  in  order  to  exclude  any  organic  disease.  W^hen  all  the 
organs,  including  those  of  the  alimentary  canal,  are  found  to  be 
healthy,  and  there  is  complaint  of  pain,  discomfort,  or  any 
symptom  directly  or  indirectly  referable  to  the  stomach,  espe- 
cially during  the  period  of  digestion,  it  may  be  attributed  to 
nervous  dyspepsia.  If  it  is  very  fitful  and  changeable,  now 
here,  now  there,  depending  much  more  upon  the  mood  or  asso- 
ciations and  surroundings  of  the  patient  than  upon  the  quality 
or  quantity  of  food  ingested,  it  will  tend  to  confirm  the  diag- 
nosis. It  is  often  extremely  difficult  to  exclude  positively  the 
existence  of  a  mild  form  of  gastric  or  intestinal  catarrh,  or 
ulcer,  not  to  mention  incipient  cancer,  and  it  is  by  no  means 
possible  to  make  the  decision  after  a  single  examination,  how- 
ever complete  and  expert,  including  a  single  analysis  of  the 
gastric  contents  or  feces.    Without  a  resort  to  the  recent  exact 


NERVOUS    DYSPEPSIA  875 

methods  of  examination,  any  diagnosis  must  be  only  a  more 
or  less  shrewd  guess. 

To  exclude  gastric  catarrh  you  will  need  to  ascertain  by 
lavage  either  that  there  is  no  considerable  amount  of  mucus  in 
the  stomach,  or,  if  mucus  be  found  in  the  wash  water,  that  it 
comes  from  the  nose,  throat,  or  oesophagus — that  it  was  not 
secreted  in  the  stomach.  In  doubtful  cases  a  microscopic  ex- 
amination of  portions  of  the  gastric  epithelium  may  be  neces- 
sary to  decide. 

You  will  be  able  to  exclude  hyperchlorhydria  and  anacidity 
or  hypoacidity  of  inflammatory  or  degenerative  origin  by  care- 
ful analyses  of  the  stomach  contents,  which  may  have  to  be 
made  more  than  once.  If  you  find  as  a  constant  condition  dur- 
ing digestion  a  large  excess  of  HCl,  the  case  will  be  either  one 
of  hyperchlorhydria  or  acid  gastric  catarrh,  unless  there  should 
be  also  an  excess  during  a  fasting  period,  when  the  trouble 
would  be  Reichmann's  disease,  or  unless  there  should  be  pro- 
nounced tenderness  on  pressure  over  the  region  of  the  stomach, 
hemorrhage,  or  the  peculiar  aggravation  of  pain  from  taking 
food,  which  is  characteristic  of  gastric  or  duodenal  ulcer,  in 
which  case  that  disease  should  be  strongly  suspected.  A 
slightly  diminished  secretion,  or  marked  variability  of  secre- 
tion, would  not  be  inconsistent  with  a  diagnosis  of  nervous  dys- 
pepsia, but  when  there  is  constantly  found  a  very  marked  defi- 
ciency of  HCl,  the  diagnosis  should  be  hypochlorhydria,  and 
when  there  is  an  absence  of  secretion  the  disease  should  be 
called  anadenia  gastrica  or  achylia  gastrica.  Lessened  secretion 
with  the  microscopic  findings  of  chronic  asthenic  gastritis 
would  point  to  that  disease,  unless  there  should  be  a  palpable 
tumor  or,  with  a  very  marked  cachexia  or  hemorrhages,  the 
Boas-Oppler  bacillus  should  be  found  in  the  wash  water,  when 
the  more  probable  diagnosis  w^ould  be  carcinoma,  complicated, 
as  it  usuall}^  is,  by  gastritis.  The  presence  of  a  decided  percent- 
age of  lactic  acid  would  also  tend  to  confirm  the  diagnosis  of 
cancer,  though  not  incompatible  with  an  aggravated  form  of 
chronic  catarrh  of  the  stomach.   Such  a  careful  and  painstaking 


876  THE    GASTRO-INTESTINAL    CLINIC 

exclusion  of  possible  gastric  diseases  is  necessary,  because  the 
depressed  nervous  condition  which  is  characteristic  of  nervous 
dyspepsia,  and  even  the  complete  symptom-complex  of  neuras- 
thenia, are  frequently  present  in  hypochlorhydria  as  well  as  in 
both  cancer  and  chronic  asthenic  gastritis  especially,  and  may 
be  in  ulcer  or  hyperchlorhydria,  particularly  when  these  have 
been  of  long  standing.  Chronic  intestinal  catarrh  with  consti- 
pation is  probably  one  of  the  most  frecjuent  causes  of  dyspeptic 
symptoms  which  are  constantly  diagnosed  as  nervous  dyspep- 
sia. Derangements  of  the  liver,  catarrh  of  the  bile-ducts,  etc., 
are  other  very  common  causes  of  such  symptoms,  and  when 
not  accompanied  by  jaundice  are  often  overlooked.  Then,  the 
various  diseases  of  the  pancreas,  which  have  only  recently  been 
studied  with  any  thoroughness  or  promising  results,  are  doubt- 
less responsible,  in  part  at  least,  for  a  large  amount  of  the  dis- 
tress which  is  labeled  nervous  dyspepsia. 

Prognosis. — Nervous  dyspepsia  is  generally  curable  and,  if 
uncomplicated,  should  never  prove  fatal.  But  when  there  is  a 
strong  inherited  tendency  to  neurasthenia,  the  cure  may  be  very 
difficult  and  prolonged.  In  such  cases,  too,  it  is  often  an  in- 
dispensable condition  that  the  patient  shall  be  in  a  position  to 
have  a  complete  rest  from  injurious  pursuits  or  excessive 
activity  of  any  kind,  if  not  actual  rest  in  bed  for  a  few  weeks; 
or  at  least  a  change  from  a  sedentary  or  professional  occupation 
to  an  outdoor  life,  and,  temporarily  at  least,  from  a  residence 
in  a  city  or  large  town  to  one  in  the  country,  mountains,  or  at 
the  seashore. 

Treatment. — If  the  case  has  been  correctly  diagnosticated, 
and  is  very  severe  or  of  long  standing,  it  is  well  to  begin  with 
some  modification  of  the  Weir  Mitchell  rest  treatment,  espe- 
cially when  the  patient  is  a  woman.  Rest  in  bed  and  seclusion, 
with  full  regulated  feeding,  massage  and  electricity  for  four 
to  eight  weeks,  followed  by  gradually  increased  exercise  in 
some  healthy  climate  out  of  doors,  will  of  itself  go  far  toward 
curing  many  cases.  But  when,  instead  of  true  nervous  dys- 
pepsia, the  case  is  one  of  neurasthenia  complicated  with  or 


NERVOUS    DYSPEPSIA  877 

resulting  from  gastric  catarrh,  and  especially  if  there  be  a  con- 
siderable displacement  or  dilatation  of  the  stomach,  as  is  so 
exceedingly  common  in  neurasthenic  women,  the  rest  cure,  if 
carried  out  without  regard  to  the  gastric  trouble,  is  usually  not 
very  successful,  and  sometimes  even  aggravates.  In  gastric 
dilatation  it  is  contra-indicated,  unless  considerably  modified, 
since  the  liquid  diet  then  disagrees  from  the  start. 

Men  need  to  be  given  a  long  vacation  from  business  and  kept 
out  in  the  open  air.  A  hunting  or  camping  trip  of  several 
weeks,  or  a  long  sea  voyage,  often  accomplishes  wonders. 
And  afterward  there  should  be  such  a  complete  reform  of  the 
patient's  mode  of  life  as  to  insure  more  hours  for  recreation 
and  sleep  and  a  less  strain  upon  the  nervous  system. 

Depressing  or  injurious  habits  of  all  kinds  must  of  course  be 
abandoned.  Spending  regularly  an  hour  or  two  daily  out  of 
doors  during  the  remainder  of  life,  on  horseback,  or  walking, 
or  driving  (or  on  a  wheel,  provided  care  be  used  not  to  over- 
exert), will  usually  complete  the  cure  and  render  it  permanent. 

As  to  diet,  while  very  indigestible  dishes  are  better  avoided, 
there  is  need  of  full  nutritious  feeding,  and  there  should  be 
such  a  variety  of  well-prepared  viands  as  to  tempt  the  appetite, 
since  in  the  majority  of  these  cases  too  little  food  is  taken. 

Both  central  galvanisation  and  general  faradization  are  help- 
ful and  static  electricity  sometimes  accomplishes  still  more. 
Abdominal,  or  better  yet,  full  general,  massage  nearly  always 
effects  good  results — indeed  may  cure  of  itself — that  is,  pro- 
vided the  disease  is  nervous  dyspepsia  and  nothing  else.  If 
there  is  hyperchlorhydria  or  acid  gastric  catarrh,  instead,  as  in 
a  certain  proportion  of  the  cases  so  classed,  abdominal  massage 
vigorously  given  will  do  harm  decidedly.  In  the  cases  as- 
sociated with  a  spastic  condition  of  the  intestinal  musculature 
resulting  in  constipation  and  painful  collections  of  gas  confined 
in  knuckles  of  the  bowels,  the  massage  over  that  region,  if  any 
at  all  is  given,  needs  to  be  very  gentle  and  soothing,  without 
any  percussion,  slapping,  hacking,  or  other  exciting  procedures. 
It  should  not  include  even  deep  kneading. 


878  THE    GASTRO-INTESTINAL    CLINIC 

Tlic  drug  treatment,  when  any  drugs  are  necessary,  should 
be  much  the  same  as  that  for  neurasthenia  generally — nerve 
tonics  and  tissue  builders  mainly,"  such  as  iron,  arsenic,  gold, 
the  hypophosphites  and  especially  the  glycerophosphates. 
Especially  useful  in  my  hands  has  been  a  combination  of  so- 
dium glycerophosphates  with  strychnine.  In  a  majority  of 
cases,  however,  little  or  no  medication  will  be  recjuired,  pro- 
vided the  hygienic  and  dietetic  treatment  already  outlined  is 
properly  carried  out.^ 

When  the  gastric  juice  is  deficient — as  it  so  often  is  in  such 
cases — you  will  nearly  always  obtain  good  results  from  ad- 
ministering HCl  and  some  active  preparation  of  pepsin,  but 
for  some  cases  one  of  the  preparations  of  papain  may  be 
equally  effective.  Constipation  should  be  overcome,  if  pos- 
sible, by  diet,  massag"e,  electricity,  or  vibration,  and  gymnastics 
with  the  help  of  enemas  of  olive  or  cotton-seed  oil  (though, 
during  the  rest  treatment,  aloes  or  cascara  is  often  necessary), 
and  riding  horseback  is  a  good  adjuvant.  (See  Lecture  on 
Constipation.)  In  the  .cases  in  which  there  is  a  decided 
tendency  to  '^a  excessive  secretion  of  HCl,  calcined  magnesia 
or  sodium  sulphate  usually  suits  better  than  the  bitter  tonic 
laxatives. 

For  the  worst  cases  a  permanent  abandonment  of  sedentary, 
or  a  too  engrossing  professional  occupation  is  necessary,  and  a 
change  from  the  city  to  the  country  or  shore  usually  conduces 
to  a  cure. 

1  A  too  prolonged  course  of  any  of  the  active  tonic  medicines  often  does 
harm  in  neiirasthenia  of  whatever  form  by  overstimulating  and  further 
exhausting  the  nervous  system — inciting  to  greater  exertion  vi'hen  rest  is 
the  real  need. 


LECTURE  LXXVIII 
NEUROSES    OF  THE   INTESTINES 

Most  of  the  affections  generally  considered  under  the 
above  head  are  of  either  complicated  or  obscure  origin.  The 
subdivision  Secretory  Neuroses  is  often  made  to  include  Mem- 
branous Catarrh  (Colica  Mucosa),  and  under  either  this  or 
Motor  Neuroses  are  classified  Constipation  and*  Diarrhea. 
There  doubtless  are  nervous  forms  of  all  these  diseases.  But 
they  are  large  and  many-sided  subjects,  which  require  a  broad 
and  general  consideration  in  all  their  phases.  Constipation,  for 
example,  is  as  much  a  secretory  as  a  motor  neurosis,  and  is  a 
symptom  of  many  organic  diseases.  I  have  deemed  it  best, 
therefore,  to  refer  briefly  to  the  unimportant  nervous  forms  of 
diarrhea,  along  with  the  other  types  of  the  same  disease,  in  a 
separate  lecture,  and  to  devote  an  entire  lecture  also  to  con- 
stipation, as  well  as  to  the  interesting  subject  of  Membranous 
Catarrh  of  the  Intestines,  under  which  head  both  the  neurotic 
and^the  inflammatory  type  of  that  disease  are  considered. 

Intestinal  colic,  which  most  authors  exclude  from  the  neu- 
roses altogether,  seems  to  me  to  be  an  especially  complex  neu- 
rosis involving  both  the  motor  and  sensory  nerves  of  the 
bowel  surely,  and  possibly  also  the  secretory.  Meteorism,  or 
an  excessive  amount  of  flatus  in  the  intestines,  may  be  partial, 
caused  then  by  obstruction  of  one  or  more  coils  through  dis- 
placement, kinking  or  otherwise,  or  may  be  general,  in  which 
case  it  is  manifestly  due  chiefly  to  atony  of  the  bowel,  along 
with  possibly  a  derangement  of  the  absorptive  function  of  the 
intestinal  mucosa,  the  former  .of  which  is  clearly  neurosal,  and 
the  latter  of  which  may  be. 

The  neuroses  of  the  intestines  which  are  not  discussed  in 
special  separate  lectures  shall,  therefore,  be  here  grouped  as 

879 


880  THE    GASTRO-INTESTINAL    CLINIC 

their  aetiology  and  relations  suggest,  without  attempting  to 
classify  them  under  the  separate  subheads  Secretory,  Sensory, 
and  Motor. 

ENTERALGIA,    INTESTINAL    COLIC,    ENTEROSPASM,   AND 

METEORISM 

Enteralgia  may  exist  by  itself  as  a  sensory  neurosis  of  the 
intestines — or  at  least  of  the  corresponding  nerve  plexus  of 
the  sympathetic — a  neuralgia  then  pure  and  simple.  With  it 
there  is  often  associated,  though  not  necessarily,  a  spasmodic 
contraction  of  the  intestinal  muscles  showing  an  irritation  of 
the  motor  nerves  also.  This  combination  constitutes  intesti- 
nal colic,  which,  however,  may  also  have  other  causes.  When  _ 
there  are  irregular  contractions  of  both  the  longitudinal  and 
circular  muscular  fibers  of  the  intestines  at  once  without  pain, 
there  results  enterospasm,  and  some  would  include  under  the 
head  enterospasm  cases  of  prolonged  tonic  spasm  of  the  bowel 
with. pain,  while  admitting  that  the  latter  cannot  be  differen- 
tiated from  colic.  In  enterospasm  the  abdomen  is  likely  to  be 
either  flat  or  boat-shaped  (retracted),  when  the  larger  part  of 
the  intestine,  and  especially  when  the  entire  intestine,  is  in- 
volved, as  in  lead  poisoning  or  basilar  meningitis,  particularly 
the  tubercular  form. 

In  metcorism  or  tympanites  there  is  primary  or  secondary 
paresis  of  some  part  or  all  of  the  intestines,  with  a  resulting 
distention  of  the  latter,  and  often  great  swelling  of  the  belly. 
The  secondary  forms  may  result  from  any  of  the  various 
causes  of  obstruction. 

These  different  affections  are  all  closely  related,  and  involve 
primarily  or  secondarily  derangements  of  one  or  more  of  the 
sets  of  nerves  supplying  the  intestines.  All  are  accompanied  by 
constipation,  more  or  less  obstinate.  Indeed,  spastic  consti- 
pation is  a  very  troublesome  condition  which  may  result  di- 
rectly from  an  enterospasm  in  some  part  of  the  bowel. 

Grouping  these  allied  disorders  facilitates  an  understanding 
of  their  causes,   relations,   and  the   therapeutic  methods   re- 


NEUROSES    OF    THE    INTESTINES  88 1 

quired.     After  describing  them  separately  I  shall  consider  the 
treatment  of  the  entire  group. 

Enteralgia. — In  certain  conditions  of  the  system,  especially 
in  lithsemia,  or  what  the  French  call  arthritism,  as  well  as  in 
malaria,  gout,  and  syphilis,  you  may  possibly  encounter  neu- 
ralgia in  any  nerve  of  the  body,  including,  of  course,  those  of 
the  stomach  and  in  any  part  of  the  intestines.  The  different 
plexuses  of  the  abdominal  sympathetic  are  often  thus  affected, 
and  Max  Buch^  maintains  that  so-called  enteralgia  is  really 
always  situated  in  some  one  of  these.  The  pain  may  be  very 
acute  and  severe,  or  merely  a  dull,  wearying  ache,  which  in- 
terferes with  the  patient's  sleep.  Acute  pain  in  any  part  of 
the  abdomen  may  be  attributed  to  neuralgia,  when  there  is  no 
fever  or  other  sign  of  inflammation,  no  tumor,  and  no  accumu- 
lation of  flatus  as  in  colic.  While,  in  the  latter,  pressure  most 
commonly  relieves  the  pain  somewhat,  there  will  usually  be  in 
enteralgia  some  tenderness  on  deep  pressure,  especially  over  the 
position  of  whichever  nerve  plexus  is  involved;  but  the  diag- 
nosis between  a  pure  enteralgia  and  colic  cannot  always  be 
made.  You  should  avoid  mistaking  for  enteralgia  especially 
malignant  growths  in  which  pain  is  likely  to  be  rather  constant, 
while  that  of  the  former  is  usually  paroxysmal;  also  chronic 
appendicitis  in  which  the  tenderness  is  commonly  located  in  or 
near  the  cecal  region  and  is  nearly  always  accompanied  by  an 
unusual  tension  in  the  right  rectus  muscle.  In  hepatic  colic 
there  is  usually  at  least  beginning  jaundice  with  pale  feces 
and  high-colored  bile-stained  urine,  while  the  pain  is  situated 
in  the  region  of  the  gall  bladder.  In  renal  colic,  the  pain 
shoots  down  along  the  course  of  the  ureter  and  is  nearly  al- 
ways accompanied  by  a  frequent  desire  to  urinate.  In  movable 
kidney  there  may  be  attacks  of  acute  pain,  but  the  situation  of 
the  pain  is  then  below  the  liver,  in  front  (more  likely  there- 
fore to  be  confounded  with  that  of  gall-stone  colic),  and  with  a 
little  practice  you  may  easily  palpate  the  kidney  in  its  abnormal 
position.  Besides,  when  a  displaced  kidney  is  painful,  it  will 
usually  be  tender  as  well  as  somewhat  swollen. 
1  Arch,  d.  Verdauungskrankh.,  ix,  4  and  5. 


882  THE    GASTRO-INTESTINAL    CLINIC 

Intestinal  Colic. — This  disease  is  so  often  seen  by  every 
practitioner  as  scarcely  to  need  description.  The  conjunction 
of  violent  paroxysmal  pain,  with  a  manifest  accumulation  of 
gas  and  constipation,  following  as  a  rule  some  indiscretion  in 
diet,  is  a  familiar  picture.  The  pain  is  intense,  and  may 
usually  be  relieved  somewhat  by  pressure  over  the  abdomen. 
Colic  or  cramp  pains,  whether  in  the  stomach  or  bowels,  are 
caused  by  some  irritant.  This  may  be  in  severe  cases  any 
cause  of  obstruction  as  hardened  feces,  gall  stones,  worms, 
etc.,  but  is  most  frequently  indigestible  food  or  an  excessive 
amount  of  acid,  either  the  HCl  of  the  gastric  juice  (which  is 
very  often  the  irritant)  or  the  organic  acids  resulting  from 
fermentation.  As  a  result  of  such  irritation  there  ensue,  in- 
stead of  the  normal  relaxation  of  one  part  of  the  gut  while  the 
part  immediately  above  contracts,  irregular  contractions  which 
do  not  yield  to  the  peristaltic  waves.  In  consequence,  the  pro- 
pulsive efforts  are  greatly  inoreased  in  force  and  frequency. 
The  bowel  contents  are  violently  driven  on  into  the  narrowed 
part,  thus  giving  rise  to  intense  pains. 

The  absence  of  fever  differentiates  intestinal  colic  at  once 
from  the  more  serious  inflammatory  affections,  and  the  dif- 
ferential diagnosis  from  the  more  frequent  non-inflammia- 
tory  causes  of  abdominal  pain  is  much  the  same  as  in  the  case  of 
enteralgia.  From  lead  colic  it  can  be  easily  distinguished  by  the 
absence  of  any  tympany  as  well  as  by  the  presence  usually  of 
a  blue  line  on  the  gums  in  the  latter. 

Enterospasm  involving  either  all  the  intestines,  or  all  except 
the  colon,  is  very  rare  except  as  a  result  of  basilar  meningitis  or 
lead  poisoning.  In  the  latter  there  is  usually  a  particularly 
severe  colic,  as  well  as  a  blue  line  at  the  junction  of  the  gums 
with  the  teeth,  so  that  this  form  of  the  malady  should  be  easily 
recognized.  In  enterospasm  dependent  upon  meningitis,  there 
is  nearly  always  at  least  a  slight  rise  of  temperature,  which 
should  help  you  to  differentiate  it.  There  will  be  also  a  pe- 
culiar hypersemia  of  the  skin  in  most  cases,  so  that  when  the 
finger,  or  especially  the  finger  nail,  is  drawn  quickly  over  the 


NEUROSES    OF    THE    INTESTINES  883 

surface  of  the  body,  a  red  streak  remains  for  some  seconds 
along  its  course.  The  typical  retraction  of  the  abdomen  with 
marked  depression  in  its  center,  called  "  boat  belly,"  is  seen 
most  perfectly  in  enterospasm  resulting  from  meningitis, 
though  it  is  often  also  well  marked  in  lead  poisoning.  In  the 
exceedingly  rare  cases  of  supposed  enterospasm  described  in 
medical  literature  which  were  not  dependent  upon  either  of 
these  two  diseases,  there  does  not  seem  to  have  been  a  marked 
general  contraction  of  the  abdomen.  In  enterospasm,  there  is, 
as  a  rule,  very  obstinate  constipation — obstipation — ^but  in  the 
partial  or  milder  types  of  the  affection  which  form  the  basis  of 
chronic  spastic  constipation,  there  may  be  bowel  movements  of 
a  peculiar  character,  either  very  small  and  slender — lead- 
pencil-sized  stools — or  little  hardened  balls  like  bullets  or 
marbles. 

You  will  rarely,  if  ever,  meet  with  a  case  of  enterospasm 
from  purely  nervous  causes,  not  a  result  of  either  meningitis 
or  lead  poisoning,  but  such  have  been  observed  by  Ewald  and 
by  Hemmeter,  among  others.  Some  of  the  reported  cases, 
however,  were  complicated  with  spasmodic  pain  and  could  be 
classified  under  Intestinal  Colic,  except  that  there  was  retrac- 
tion of  the  abdomen  instead  of  tympany,  as  is  usual  in  colic. 
In  any  such  case  we  cannot  positively  exclude  lead  colic,  since 
the  blue  line  on  the  gums  is  often  wanting  in  persons — plum- 
bic patients — who  take  good  care  of  their  teeth,  while  the  other 
signs  of  lead  poisoning  may  often  fail  us,  and  there  may  be 
nothing  in  the  most  carefully  developed  history  to  suggest 
that  origin  in  some  of  the  worst  cases  of  such  poisoning.  Lo- 
calized spasm  in  some  one  or  more  parts  of  the  bowel  pro- 
duces spastic  constipation  without  any  marked  appearance  of 
abdominal  retraction. 

Meteorism,  Tympanites,  or  Flatulency Colic  might  have 

been  described  as  enteralgia  or  pain  in  the  bowels  plus  a 
gaseous  distention  of  them,  and  the  commoner  forms  of 
meteorism  may  be  defined  as  a  gaseous  distention  without  the 
violent  paroxysmal  pain  which  is  characteristic  of  colic.     Still 


884  THE    GASTRO-INTESTINAL    CLINIC 

there  is  usually  much  discomfort  or  dull  pain  in  meteorism,  and 
when  the  condition  is  due  to  inflammatory  causes  as  appendi- 
citis, peritonitis,  etc.,  the  pain  may  be  severe. 
The  cause  of  meteorism  may  be : 

1.  A  local  obstruction,  such  as  a  twist  or  displacement  in- 
VQlving  a  kinking  of  some  portion  of  the  intestine,  intussus- 
ception or  invagination,  a  contraction  with  narrowing  of  the 
lumen  from  the  cicatrix  of  an  ulcer,  the  pressure  of  a  tum.or  or 
displaced  kidney,  inflammatory  adhesions  attaching  one  coil  of 
intestine  to  another  coil  or  to  some  other  organ,  a  blocking  of 
the  bowel  by  a  large  gall  stone  or  by  a  mass  of  hardened  feces, 
or  hernia,  appendicitis,  peritonitis,  typhoid  fever,  etc.,  spastic 
contractions  producing  constipation,  or  constipation  from  any 
cause. 

2.  The  excessive  formation  of  gas  in  either  the  stomach  or  in- 
testine through  fermentation  or  putrefaction,  with  the  addition 
of  the  gas  in  any  effervescent  beverages  ingested,  and  increased 
possibly  in  some  cases  to  a  certain  extent  by  swallowed 
air. 

The  suggestion  that  air  sucked  in  through  the  rectum  may 
be  responsible  for  some  cases  of  excessive  distention  of  the 
intestine  seems  too  ridiculous  for  serious  consideration. 

3.  An  unquestionably  important  factor  in  the  aetiology  of 
meteorism  in  many  cases,  if  not  the  chief  cause,  is  atony  of  the 
bowel  wall,  which  allows  even  the  normally  small  amount  of 
gas  formation  to  produce  an  undue  distention,  and  at  the  same 
time  retards  the  onward  propulsion  of  the  bowel  contents. 

4.  Deficient  absorption  of  gases  through  some  defect  in  the 
mucosa  may  be  a  cause  of  excessive  tympany,  though  it  is  dif- 
ficult to  prove  this  beyond  question. 

The  symptoms  of  meteorism  include  constipation,  marked 
distention  of  the  abdomen,  which  in  severe  cases  becomes  bar- 
rel-shaped, and,  in  its  worst  forms,  pain  which  is  usually  dull 
and  constant  rather  than  paroxysmal.  When  the  distention  is 
extreme  the  stomach  and  diaphragm  are  pushed  upward 
against  the  heart,  and  there  is  then  often  vomiting  as  well  as 


NEUROSES    OF    THE    INTESTINES  885 

possibly  palpitation,  dyspnea,  and  sometimes  even  faintness  or 
collapse. 

Diagnosis. — Percussion  gives  a  loud  tympanitic  note  all  over 
the  abdomen,  including  the  sides,  where  in  ascites  there  would 
be  dullness  instead.  Then  in  the  middle  line  the  abdomen  is 
high  and  rounded  instead  of  flattened  there  with  prominent 
bulging  at  the  sides,  as  there  would  be  in  ascites.  Furthermore, 
in  tympanites  no  wave  of  licjuid  can  be  driven  across  from  one 
side  to  the  other  by  a  tap  from  one  hand,  so  as  to  be  felt  as  an 
impact  by  the  other  hand  while  palpating  on  the  opposite  side. 
It  must  not  be  forgotten,  however,  that  in  peritonitis,  especially 
when  it  results  from  the  escape  of  the  gastric  contents  through 
a  perforated  ulcer,  liquid  may  be  demonstrated  in  the  ab- 
dominal cavity  on  one  or  both  sides,  the  tympanites  being  then 
only  one  symptom  of  a  serious  complicated  condition. 

In  simple  meteorism,  not  a  result  of  perforation  with  escape 
of  gas  into  the  peritoneal  cavity,  the  liver  may  be  pushed 
upward  so  that  its  zone  of  dullness  is  higher  than  normal,  but 
the  latter  is  rarely  entirely  obliterated,  as  it  is  when  there  has 
been  perforation  of  the  stomach  or  intestines.  Absence  of  the 
usual  liver  dullness  may  be  produced  also  by  the  displacement 
upward  of  a  much  distended  colon,  so  that  too  much  importance 
should  not  be  attributed  to  this  sign. 


PERISTALTIC  UNREST;  ATONY  AND  PARALYSIS  OF  THE 

INTESTINES 

Peristaltic  unrest  of  the  intestines  is  in  all  respects  analo- 
gous to  peristaltic  unrest  of  the  stomach.  When  a  mere  neu- 
rosis it  affects  predominantly  the  same  class  of  persons — 
those  possessing  an  unstable  nervous  system — but  may  be  en- 
countered also  in  strong  persons  as  a  result  of  inflammatory 
disease  or  any  mechanical  cause  of  obstruction  to  the  onward 
propulsion  of  the  feces. 

As  in  the  stomach,  peristaltic  restlessness  in  the  intestines 
consists  of  excessive  or  exaggerated  peristaltic  movements, 


886  THE    GASTRO-INTESTINAL    CLINIC 

which  in  thin  persons  can  often  be  seen  or  felt  by  the  palpat- 
ing hand. 

The  cetiology  can  be  various.  The  affection  is  generally 
classed  among  the  neuroses,  and  nervous  causes  are  supposed 
to  be  sufficient  alone  to  produce  it;  but  it  is  a  curious  fact 
that,  though  the  essence  of  the  trouble  is  excessive  peristalsis, 
it  is  only  exceptionally  seen  in  diarrhea,  when  the  exciting 
cause  of  the  latter  doubtless  produces  it,  but,  on  the  contrary, 
is  nearly  always  associated  with  constipation,  which  it  is  sup- 
posed to  cause.  I  hope  not  to  be  condemned  as  hopelessly 
heterodox  if  I  venture  to  suggest  that  the  constipation  may 
be  the  primary  condition — the  cause — and  the  neurasthenic 
state  and  associated  peristaltic  unrest  may  be  results. 

In  addition  to  the  nervous  cases,  it  is  well  understood  that 
any  of  the  numerous  forms  of  intestinal  obstruction  which  have 
been  already  discussed  may  be,  and  usually  are,  accompanied 
by  peristaltic  unrest. 

The  symptoms  in  the  milder  cases  include  merely  the  con- 
sciousness of  excessive  movements  in  the  intestines,  or  actual 
discomfort  produced  by  them,  together  with  the  gurgling  and 
rumblings  which  are  audible  both  by  the  patient  and  others. 
As  a  rule,  the  trouble  is  not  persistent,  but  occurs  in  recurrent 
attacks  which  may  last  for  variable  lengths  of  time,  but  usually 
for  a  few  hours  only.  In  some  cases  the  discomfort  of  the  un- 
usual movements  increases  to  actual  pain,  and  severe  cases  of 
this  kind  are  scarcely  to  be  diagnosed  from  intestinal  colic,  es- 
pecially when  some  tympanites  is  also  present.  Most  authors 
have  observed  that  the  affection  occurs  chiefly  in  nervous  per- 
sons, especially  in  women,  and  in  the  latter  is  worse  at  the 
monthly  periods  as  well  as  during  pregnancy. 

The  diagnosis  can  only  be  made  from  the  above-mentioned 
symptoms,  especially  by  seeing  or  feeling  the  exaggerated 
movements.  The  neurotic  form  may  be  distinguished  from 
those  cases  due  to  intestinal  obstruction  by  the  comparative 
mildness  of  the  symptoms,  and  especially  by  the  fact  that  they 
do  not  persist  right  along  as  do  the  latter,  but  have  periods  of 


NEUROSES    OF    THE    INTESTINES  887 

remission,  and  usually  cease  whenever  the  patient's  attention 
is  diverted  by  spirited  conversation  or  any  engrossing  occu- 
pation. 

Paralysis  of  the  Intestines. — This  disease  may  be  a  neu- 
rosis, but,  as  most  frequently  encountered,  is  a  consequence  of 
certain  anatomic  lesions,  mostly  surgical  affections.  For  the 
sake  of  convenience  the  whole  subject  shall  be  here  briefly 
considered. 

Complete  paralysis  of  the  intestines  generally  is  rare,  and  is 
a  result  either  of  diffuse  peritonitis,  or  of  some  central  nervous 
disease,  such  as  tumors  of  the  brain  or  cord,  meningitis,  loco- 
motor ataxia,  myelitis,  hysteria,  melancholia,  etc.  Exception- 
ally it  may  result  reflexly  from  traumatism  in  some  of  the 
more  sensitive  sexual  organs — ovaries  or  testicles — through 
operation  or  accidental  injury. 

Paralysis  of  a  single  coil  or  small  part  of  the  intestines  is 
often  seen  and  may  result  from  a  local  peritonitis,  abscess, 
severe  enteritis,  appendicitis,  replacement  of  a  hernia,  an  ac- 
cumulation of  hardened  feces,  volvulus,  intussusception,  dis- 
placement of  almost  any  of  the  viscera  (especially  when  kink- 
ing is  thus  produced),  tumors,  obturation  by  a  large  gall  stone, 
and  In  short  any -of  the  mechanical  or  other  causes  which  can 
obstruct  the  lumen  of  the  intestines  when  such  a  cause  per- 
sists long. 

The  symptoms  are  extreme  meteorism,  obstipation,  eventu- 
ally vomiting  (often  of  fecal  matter),  pain,  great  restlessness, 
cardiac  palpitation,  weakness,  and,  unless  relief  can  be  af- 
forded, collapse  and  death. 

The  diagnosis  of  intestinal  paralysis  can  be  made  when  ex- 
treme meteorism  exists  in  the  absence  of  any  discoverable 
cause  of  obstruction,  or  persists  for  many  days  in  spite  of  the 
removal  of  the  obstruction.  Indeed,  since  obstruction  of  the 
bowel  can  finally  lead  to  paralysis,  this  condition  may  be  in- 
ferred when  a  high  degree  of  meteorism  persists  long,  because 
of  the  non-removal  of  the  obstruction. 

Prognosis. — Paralysis  of  the  intestines,  or  any  part  of  them, 


888  THE    GASTRO-INTESTINAL    CLINIC 

can  usually  be  cured  when  the  cause  can  be  completely  removed 
within  a  short  time — a  few  days.  But  when  the  primary 
disease  or  mechanical  obstruction  is  irremediable,  there  can 
naturally  be  no  hope.  When  the  cause  has  persisted  very  long, 
even  its  removal  will  not  be  likely  to  be  followed  by  a  return 
of  power  to  the  intestinal  muscles. 

^  The  Treatment  of  the  Intestinal  Neuroses. — In  all  of  the 
true  neuroses,  however  manifested,  the  primary  indication 
must  be  to  strengthen  in  every  way  the  weakened  nervous 
system.  You  must  treat  the  neurasthenia  or  hysteria  which  is 
the  fundamental  disease.  The  most  efficient  therapeutic  meas- 
ures and  medicines  for  this  purpose  have  already  been  fre- 
quently discussed  in  this  series  of  lectures,  especially  under  the 
heading  of  the  Treatment  of  Nervous  Dyspepsia,  but  the  sub- 
ject is  so  important  that  the  principal  remedies  will  be  here 
again  summarized. 

The  therapeutic  means  which  are  of  universal  application  in 
all  such  cases  are : 

1.  All  enlivening  and  encouraging  psychic  influences. 

2.  A  generous  and  nourishing  diet,  as  abundant  and  varied 
as  the  patient's  digestive  powers  and  purse  will  permit. 

3.  The  inhalation  of  as  much  of  a  pure,  bracing,  outdoor  air 
(outside  of  cities  when  practicable)  as  can  be  taken  into  the 
lungs,  though  in  the  worst  cases  of  neurasthenia  it  needs  often 
to-  be  inspired  while  the  patient  is  resting  in  a  recumbent  po- 
sition, rather  than  exercising. 

4.  A  full  or  even  extra-large  amount  of  sleep,  not  forced  by 
hypnotics,  though  the  use  of  nerve  tonics  or  even  the  cautious 
administration  of  the  milder  stimulants  to  favor  this  is  often 
permissible,  or  even  advisable,  since  the  former  especially  may 
assist  in  other  ways  the  work  of  improving  the  lowered  nerve 
tone. 

In  addition  to  a  general  tonic  treatment,  enteralgia,  colic, 
enterospasm,  and  cases  of  meteorism  or  flatulency,  not  de- 
pendent upon  any  serious  form  of  obstruction,  all  call  for  com- 
bined sedative  and  aperient  remedies.     In  the  first  three  af- 


I 


NEUROSES    OF    THE    INTESTINES  889 

fections  in  all  of  which  pain  is  the  predominant  symptom,  and 
often  the  cause  of  intense  suffering,  an  efficient  close  of  some 
powerful  anodyne,  preferably  in  most  cases  morphine  and  atro- 
pine (grn.  Ya  of  the  former  with  grn.  1-80  of  the  latter), 
should  be  promptly  administered  hypodermically  in  cases  in 
which  the  pain  is  violent,  and  repeated  in  twenty  to  thirty 
minutes  if  there  has  been  no  relief.  Then  it  is  often  desirable 
to  order  further  amounts  of  the  same  remedies  in  doses  twice 
as  large,  to  be  administered  in  the  form  of  suppositories  by  the 
rectum.  This  is  more  efficient  in  intestinal  pains  than  cor- 
responding (half)  doses  by  the  mouth,  and  is  much  less  likely 
to  disturb  the  stomach. 

I  have  often  been  obliged  in  severe  colics  to  inject  hypo- 
dermically 1/4  grn.  of  morphine  combined  with  atropine  as 
above  described,  before  the  pain  could  be  controlled.  But 
until  you  have  tested  the  tolerance  of  a  patient  for  the  drug,  it 
is  best  not  to  give  over  >4  gi'i^-  of  morphine  at  a  dose,  and  it  is 
not  wise  in  any  case  to  inject  more  than  y2  grn.  at  a  time. 
While  the  pain  is  thus  being  relieved,  it  is  necessary  in  most 
cases  to  administer  remedies  designed  to  unload  the  bowels. 
When  there  is  no  nausea  or  vomiting,  castor  oil,  or  some  such 
disguised  preparation  of  it  as  Laxol,  will  succeed  best  given  in 
doses  of  fo  ss.  to  foi ;  or  you  may  prescribe  instead  some  agree- 
ably flavored  saline,  such  as  a  pint  bottle  of  the  familiar  effer- 
vescent solution  of  magnesia,  taken  gradually  to  avoid  nausea, 
or  the  following  prescription : 

"S,  Magnesiae  sulph §  ii 

Succi  limonis f  §i 

Aq.  menth.  pip q.  s.  ad  f  §  iv 

M.   Sig.     Teaspoonful  in  water  (preferably  carbonated)  every 
half-hour  till  it  acts. 

One  or  two  compound  cathartic  pills  may  answer  instead  of 
the  purgatives  mentioned,  though  they  must  often  be  repeated, 
and  are  too  slow  in  acting  for  the  worst  cases.  In  the  latter  the 
quickest  and  most  efficient  means  of  emptying  the  colon  is  by 
copious  enemas  of  hot  normal  salt  solution  or  warm   soap 


890  THE    GASTRO-INTESTINAL    CLINIC 

suds  alternated  with  enemas  of  olive,  linseed,  or  cotton-seed  oil, 
fsiv  to  fovi,  injected  preferably  through  a  long  flexible  tube, 
though  the  ordinary  apparatus  will  answer,  if  the  patient  lies 
first  on  the  left  side  with  the  hips  raised,  and  after  a  few 
minutes  is  directed  to  lie  on  the  right  side,  while  the  colon  is 
kneaded  in  the  reverse  direction  to  carry  the  liquid  over  into 
the  cecum. 

A  very  soothing  and  helpful  adjuvant  in  all  the^e  cases  char- 
acterized by  either  pain  alone,  or  pain,  spasm,  and  constipa- 
tion, is  the  application  of  hot  mush  or  flaxseed-meal  poultices, 
or  hot  wet  compresses  over  the  entire  abdomen,  changed  as 
soon  as  they  become  cool. 

To  prevent  the  recurrence  of  such  attacks,  besides  the  al- 
ways indispensable  tonic  measures  addressed  to  the  nen^ous 
system,  great  attention  should  bei  given  to  securing  regular  and 
sufficient  bowel  movements  by  diet  and  exercise — active  or 
passive,  or  both  according  to  the  strength  of  the  patient — aided 
when  necessary  by  oil  enemas,  and  when  not  otherwise  contra- 
indicated,  by  massage,  electricity,  and  hydrotherapeutics. 
(See  lectures  on  Constipation.) 

When  either  colic  or  meteorism  is  due  to  obstruction  of 
the  bowel,  this  primary  affection  must  receive  the  chief  atten- 
tion.    (See  lecture  on  Intestinal  Obstruction.) 

Treatment  of  Peristaltic  Unrest  of  the  Intestines. — This 
affection,  when  it  proceeds  from  nervous  causes,  neecte  the  same 
roborant  measures  appropriate  to  other  phases  of  neurasthe- 
nia, and  sometimes  in  addition  the  milder  nerve  sedatives,  such 
as  the  bromides,  valerian,  Scutellaria,  gelsemium,  cimicifuga, 
asafetida,  sumbul,  etc.  The  bowels  should  be  kept  open  by 
hygienic  means  as  advised  above.  More  serious  causes,  such 
as  intestinal  obstruction,  demand  the  treatment  appropriate  to 
the  primary  affection. 

Treatment  of  Paralysis  of  the  Intestines,  when  partial  and 
due  to  inflammatory  disease  or  mechanical  obstruction,  re- 
quires the  measures  necessary  for  the  cure  or  relief  of  such  af- 
fection.    After  this  has  been  accomplished,  or  at  once  in  cases 


NEUROSES    OF    THE    INTESTINES  89I 

attributable  to  general  depressing  conditions,  remedies  de- 
signed to  strengthen  the  intestinal  musculature  will  be  in 
order.  Strychnine  internally  or  hypodermically  has  been  gen- 
erally recommended,  and  may  be  tried,  though  some  recent  ex- 
periments failed  to  show  that  it  can  really  strengthen  muscle 
fibers ;  massage  and  electricity  locally,  vibration  over  the  lower 
spine  and  the  colon,  as  well  as  within  the  rectum,  and  some- 
times, though  not  in  very  weak  patients,  cold  douches  or  af- 
fusions to  the  abdomen,  will  be  suitable  unless  contra-indicated 
for  any  reason  because  of  the  nature  of  the  exciting  disease. 
None  of  these,  except  intra-rectal  vibration,  would  suit  when 
the  bowels  are  obstructed  by  spastic  contractions,  nor  in  any 
acute  inflammation.  Care  must  be  taken  to  have  the  bowels 
open  daily  without  unduly  irritating  the  weak  musculature, 
preferably  by  the  use  of  oil  enemas,  and  the  diet  must  be  nour- 
ishing and  digestible  without  being  either  toO'  bland  or  too  dis- 
turbing. 


LECTURE  LXXIX 

DISEASES  OF  THE  RECTUM  AND  ANUS 

J. 

It  would  be  impossible,  in  the  limited  space  allotted  to  the 
subject  in  this  book,  to  attempt  a  full  discussion  of  those  con- 
ditions of  the  rectum  which  are  influenced  by  disturbances  of 
the  digestive  functions,  or  which,  in  turn,  affect  the  nutritive 
or  digestive  processes.  An  attempt  will  be  made  to  review 
briefly  the  more  common  affections  of  the  rectum  and  anus  as 
met  with  in  general  practice,  and  to  indicate  such  methods  of 
treatment  as  have  been  found  of  service  to  the  writer,  es- 
pecially methods  which  can  be  employed  by  the  general  prac- 
titioner not  having  access  to  a  hospital  with  its  fully  equipped 
surgical  paraphernalia.  The  accepted  methods  of  operative 
procedure  in  given  cases  will  be  briefly  reviewed,  but  for  the 
full  description  of  the  technique,  the  reader  must  be  referred  to 
the  more  complete  writings  dealing  with  that  special  subject. 

Fortunately,  in  recent  years,  more  attention  has  been  paid  to 
the  important  relation  the  rectum  bears  to  the  general  gastro- 
intestinal tract,  and  it  is  to  be  hoped  the  day  will  soon  be 
numbered  with  the  past  when  a  long-continued  enteritis  or 
colitis  will  be  treated  without  a  careful  rectal  examination. 
Should  a  case  present  with  definite  rectal  symptoms,  a  local 
examination  ought  to  be  made  before  any  treatment  is  insti- 
tuted. No  sensible  patient  should  refuse  to  have  this  examina- 
tion made,  and  no  physician,  however  strongly  convinced  of 
the  diagnosis  from  the  symptoms  stated,  should  allow  himself 
to  be  lulled  into  a  sense  of  false  security  and  prescribe  for  that 
case  until,  by  careful  local  examination,  the  diagnosis  has 
been  verified.  When  a  patient  tells  you  that  he  has  an  attack 
of  the  "  piles,"  his  diagnosis  is  of  about  as  much  value  as  that 
of  an  old  countrywoman  who  had  a  bad  attack  of  cystitis,  and 


DISEASES    OF    THE    RECTUM    AND    ANUS  893 

who  told  her  doctor  that  she  had  "  an  awful  pain  in  her  stom- 
ach." The  plebeian,  but  correct  term,  "  piles,"  may  be  used  to 
express  any  rectal  condition  from  a  simple  fissure  to  carcinoma, 
such  is  the  dense  ignorance  on  the  part  of  the  average  layman 
as  to  things  rectal. 

For  the  sake  of  brevity  a  discussion  of  the  anatomy  and 
physiology  of  the  rectum  will  be  omitted,  and  only  such  men- 
tion of  the  subject  will  be  made  as  is  absolutely  necessary  for 
the  clear  understanding  of  any  particular  condition. 

EXAMINATION  OF  THE  PATIENT 

When  a  patient  presents  himself  for  treatment  it  is  very  im- 
portant to  obtain  a  clear  history  of  the  case.  This  is  best  ac- 
complished by  first  allowing  the  patient  to  give  a  'recital  of 
his  symptoms  in  his  own  words,  beginning  with  the  time  when 
he  first  became  aware  of  any  abnormal  rectal  condition.  Do 
not  interrupt  by  asking  any  questions,  for  the  man  will 
naturally  lay  stress  upon  the  .symptoms  which  appear  to  him 
most  important,  and  much  valuable  information  may  be  gained 
from  hearing  the  symptoms  detailed  in  this  manner.  Oft- 
times  a  premature  cjuestion  put  by  the  examiner  will  force  the 
patient  into  placing  too  much  importance  on  some  insignificant 
or  misleading  symptom.  After  the  patient  has  completed  his 
story,  the  time  has  arrived  to  ask  leading  questions  so  as  to 
arrive  as  nearly  as  possible  at  an  accurate  diagnosis  of  the  case, 
but  a  positive  diagnosis  is  an  impossibility  without  a  carefully 
instituted  examination,  the  history  simply  indicating  what  is 
to  be  looked  for,  and  helping  -one  to  find  obscure  conditions 
which  might  otherwise  be  overlooked. 

The  Symptoms  and  Their  Significance. — The  most  promi- 
nent symptom  usually  complained  of  is  pain,  for  unless  this  be 
present  the  patient  rarely  consults  a  physician  and  it  is  by  re- 
lieving this  one  symptom,  by  correcting  or  removing  the  cause, 
that  the  professional  man  earns  for  himself  the  gratitude  of 
the  sufferer.  Unfortunately,  recourse  is  only  too  often  had 
to  the  use  of  opiates,  and  too  often,  either  from  ignorance  or  a 


894  THE    GASTRO-INTESTINAL    CLINIC 

mistake  in  judgment,  the  foundation  is  laid  for  the  acquire- 
ment of  the  opium  or  cocain  habit.  Right  here  let  me  say- 
that  the  use  of  opium  is  hardly  ever  indicated  for  the  relief  of 
rectal  pain.  If  the  cause  can  be  ascertained  it  can  usually  be 
removed  by  very  simple  means,  and  then  the  mistake  is  not 
made,  as  is  often  done,  of  masking  very  important  guiding 
symptoms. 

The  time,  duration,  and  character  of  pain  are  very  important. 
If  felt  during  stool,  it  would  suggest  strangulation  of  anal 
tissues,  hemorrhoids,  abscess,  or  ulceration.  If  it  should  begin 
after  stool,  it  would  point  to  the  presence  of  fissure,  while,  if  it 
is  continuous  and  of  a  throbbing  character,  abscess  formation 
may  be  suspected. 

Bleeding,  during  stool  and  immediately  after,  would  indicate 
internal  hemorrhoids,  ulceration,  or  malignant  disease.  Oc- 
casionally there  may  be  a  little  bleeding  from,  a  fistulous  tract. 
In  children  the  presence  of  blood  in  the  stools  would  suggest 
the  existence  of  a  polyp. 

Itching,  as  a  symptom,  occurs  with  aggravating  frequency. 
This  may  be  a  mild,  fleeting,  and  almost  a  pleasurable  sensa- 
tion, or  it  may  be  present  in  such  an  aggravated  form  as  to 
render  the  life  of  the  patient  almost  unbearable.  Nearly  any 
rectal  condition  may  produce  itching  as  a  reflex  symptom,  but 
as  a  rule  the  correction  of  the  cause  removes  the  trouble.  Un- 
fortunately, in  cases  of  pruritus  ani  of  the  more  pronounced 
type  the  physician  will  find  that  he  has  a  very  grave  and  stub- 
born condition  to  deal  with. 

Protrusion  from  the  anus  is  usually  a  prolapsed  internal 
hemorrhoid,  a  polypus,  or  a  prolapse  of  a  portion  or  all  of  the 
rectal  coats. 

Szvellings  at  the  margin  of  the  anus  may  be  due  to  strangu- 
lation of  an  hypertrophied  anal  margin,  thrombotic  external 
piles,  anal  condylomata,  abscesses,  fatty  tumors,  or  malignant 
growths. 

Constipation,  while  a  symptom,  is  of  such  frequent  occur- 
rence, and  of  such  importance,  that  it  has  come,  in  the  lay 


DISEASES    OF    THE    RECTUM    AND  ANUS  895 

mind  at  least,  to  be  regarded  as  a  distinct  disease,  or  at  least  an 
unpleasant  abnormality.  It  is  the  hobby-horse  of  the  quack, 
and  the  stumbling-block  of  the  regular  practitioner.  Its  rectal 
relations  will  be  dealt  with  in  another  portion  of  this  lecture, 
and  the  subject  of  constipation  in  general  is  considered  in  Lec- 
tures LXIX.  and  LXX. 

Diarrhea  is  also  a  term  loosely  applied  to  discharges  from 
the  rectum  of  undue  frecjuency  or  liquid  formation,  whether 
feces,  mucus,  blood,  or  pus.  If  feces,  the  trouble  is  rarely  of 
local  origin,  but  mucus,  blood,  or  pus  may  originate  anywhere 
along  the  intestinal  tract,  and  the  location  of  the  trouble  should 
be  diligently  searched  for.  Hemorrhage  may  follow  any  ul- 
cerative condition  of  the  intestine,  as  in  typhoid  or  tubercular 
ulceration,  or  that  ulceration  taking  place  in  the  later  stages  of 
malignant  disease.  If  the  bleeding  be  from  any  point  in  the 
small  intestine,  the  discharge  will  contain  clots  of  blood, 
mixed  with  feces,  and  show  evidences  of  partial  digestion.  If 
the  clots  are  large  and  undigested,  the  hemorrhage  has  either 
been  very  free,  or  the  bleeding  has  occurred  at  some  point  in  the 
colon  or  rectum.  Should  the  bleeding  be  free  at  stool  and 
contain  few  clots,  the  cause  is  probably  to  be  found  in  the 
rectum  and  is  du€  to  the  conditions  mentioned  under  hemor- 
rhage. 

Mucus  may  result  from  almost  any  catarrhal  condition  of 
the  large  or  small  intestine,  from  polypoid  growths,  or  simply 
from  a  localized  rectitis  due  to  local  irritation.  Pus  in  the 
stool  may  also  occur  as  a  result  of  high  ulceration  or  the  rup- 
ture of  an  abscess  into  the  bowels,  or  it  may  be  of  local  origin, 
as  from  ulcerated  hemorrhoids,  perirectal  and  ischiorectal 
abscess,  or  from  carcinoma  of  the  sigmoid  or  rectum. 

It  is  also  well  to  bear  in  mind  such  symptoms  as  cough, 
rapid  loss  of  weight,  skin  eruptions,  temperature,  respiration, 
and  pulse,  as  they  may  have  a  bearing  upon  the  general  con- 
dition of  the  patient,  suggesting  phthisis,  specific  disease,  or 
malignant  development. 

Technique    of    the    Examination. — The    most    satisfactory 


896  THE    GASTRO-INTESTINAL    CLINIC 

method  of  examining  patients  is  to  place  them  on  a  lounge  or 
operating  table  in  the  left  lateral  posture,  with  the  knees  drawn 
well  up,  the  right  knee  a  little  higher  than  the  left,  and  the  but- 
tocks well  over  to  the  edge  of  the  table.  The  light  should  be 
direct,  daylight  being  preferable  to  artificial  light.  This 
posture  has  the  advantage  over  others  that  with  it  there  is  less 
exposure  of  the  person,  a  very  important  consideration  when 
dealing  with  a  female  patient,  and  also  it  is  a  very  comfortable 
position,  especially  when  the  examination  occupies  a  consider- 
able length  of  time.  There  are  few  rectal  conditions  where  any 
other  position  for  examination  is  either  necessary  or  desirable. 

Inspection  of  the  Anus,  etc. — Before  any  examination  of 
the  rectum  itself  is  made,  a  careful  inspection  should  be  made 
of  the  anus  and  surrounding  tissues.  The  skin  should  be  ex- 
amined for  abnormalities,  such  as  redness,  cracks,  swellings 
caused  by  thrombi,  inflamed  anal  folds,  ulceration,  or  the  open- 
ings of  fistulous  tracts.  Particular  notice  should  be  taken  of 
the  anal  aperture.  Normally  the  anus  should  appear  as  an 
antero-posterior  slit,  about  one  inch  in  length,  and  the  line  only 
broken  by  a  few  normal  corrugations.  Upon  separating  the 
buttocks,  should  the  aperture  appear  round  or  funnel-shaped, 
spasm  of  the  sphincter,  due  to  some  irritation,  is  undoubtedly 
present.  This  condition  is  most  pronounced  in  cases  of  fissure 
of  the  anus.  The  anal  opening  may  be  occluded  by  a  pro- 
lapsed polypus,  or  internal  hemorrhoids,  or  the  lower  extremity 
of  a  fissure  may  be  seen. 

In  patients  suffering  from  paresis  and  locomotor  ataxia, 
there  is  frecjuently,  noted  a  loss  of  tone  in  the  sphincter  re- 
flexes. \\nien  the  flnger  is  inserted  into  the  rectum  the  sense 
of  contraction  around  the  finger  is  very  slight,  while  if  a  little, 
lateral  pressure  is  made,  the  sphincter  relaxes  easily,  allowing 
the  anus  to  gape  open.  In  the  advanced  stage  of  these  diseases 
this  relaxation  increases  until  incontinence  results.  The  con- 
dition seems  to  be  due,  possibly,  to  the  diminution  of  tactile 
sensation  in  the  internal  sphincter,  associated  with  paralysis  of 
the  external  sphincter. 


DISEASES    OF    THE    RECTUM    AND   ANUS  897 

The  Digital  Examination. — After  carefully  noting  all  ex- 
ternal anal  conditions,  a  digital  examination  should  be  made. 
Lubricate  the  index  finger  either  with  petrolatum  or  other 
lubricant,  introduce  it  gently  into  the  anus,  overcoming  the 
normal  resistance  by  firm  but  gentle  pressure.  The  finger 
should  never  be  introduced  with  undue  haste,  as  uncomfort- 
able and  often  painful  spasm  of  the  sphincters  is  produced 
thereby.  In  a  normal  anus  the  finger  should  slide  in  easily, 
and  when  at  rest,  there  should  be  very  little  sensation  of  con- 
striction caused  by  the  rhythmic  contraction  of  the  muscle 
about  the  finger.  By  means  of  tactile  sensation,  the  trained 
finger  can  diagnose  most  of  the  local  diseases  affecting  the 
lower  portion  of  the  rectum,  as  for  instance,  fissure,  the  in- 
ternal opening  of  a  fistula,  polypoid  growths,  fibromata,  malig- 
nant neoplasms,  stricture,  deep  ulcerations,  foreign  bodies  and 
fecal  impaction  occuring  in  the  rectum,  fluctuation,  or  points 
of  abnormal  tenderness.  Internal  hemorrhoids  cannot  be  ac- 
curately diagnosed  in  this  manner.  It  should  be  borne  in  mind 
that  the  finger  is  the  best  instrument  for  diagnosis,  while  a 
speculum  .is  of  chief  value  only  to  verify  conclusions,  to  diag- 
nose internal  hemorrhoids,  and  particularly  is  it  an  instrument 
to  assist  in  local  treatment  of  the  rectum.  For  pathologic  con- 
ditions beyond  the  reach  of  the  index  finger,  a  speculum  is 
necessary. 

The  More  Important  Instruments  Required — The  speculum 
I  find  most  convenient  for  routine  use  is  the  small  conical  form 
designed  by  Dr.  Robert  W.  Martin.  It  will  be  noticed  by  re- 
ferring to  the  accompanying  figure  that  the  rectal  end  is  cut 
off  at  an  angle  of  45°.  A  small  wire  bead  is  added  to  this  edge 
to  protect  the  tissues  from  injury  and  also  to  add  to  the 
comfort  of  the  patient  while  rotating  the  speculum  in  the 
rectal  cavity.  The  angularity  of  the  distal  end  is  for  the  pur- 
pose of  allowing  the  side  of  the  rectal  wall  to  prolapse  into  the 
aperture,  so  that  a  distinct  view  of  the  mucosa  may  be  ob- 
tained. By  rotating  the  speculum,  every  portion  of  the  rectal 
mucosa  of  the  lower  two  inches  can  be  closely  inspected.     The 


898 


THE   GASTRO-INTESTINAL    CLINIC 


speculum  is  of  course  introduced  with  the  obturator  in  place, 
and  as  much  care  should  be  used  in  the  introduction  as  was 
used  in  passing  the  finger  into  the  rectum.    There  are  several 


Fig.  99. — Martin's  conical  speculum. 

good  forms  of  bivalve  specula  on  the  market,  but  while  they 
may  be  useful  in  some  cases,  they  have  the  disadvantage  that 
they  cannot  be  rotated  in  the  anus  without  great  pain  and  dis- 


FiG.  100. — Bodenhamer's  bivalve  speculum. 

comfort  to  the  patient,  but  have  to  be  reintroduced  every  time 
a  new  section  of  the  rectal  cavity  is  to  be  examined. 

One  of  the  most  convenient  forms  is  that  designed  by  Boden- 
hamer,  a  cut  of  which  is  shown. 


DISEASES   OF   THE   RECTUM    AND   ANUS 


899 


While  it  must  be  borne  in  mind  that  a  large  percentage  of 
rectal  conditions  can  be  diagnosed  simply  by  digital  examina- 
tion followed  by  the  use  of  a  small  speculum,  there  are  other 
diseases  of  the  upper  rectum  and  sigmoid  for  the  diagnosis  of 
which  an  extra-long  speculum  or  pneumatic  proctoscope  is 
necessary. 

Dr.  Tuttle  has  kindly  permitted  me  to  use  the  cut  of  his 
proctoscope,  and  I  have  taken  the  liberty  of  cjuoting  the  excel- 


FiG.  lor. — Tattle's  pneumatic  proctoscope. — A,  obturator;  B,  plug  with 
glass  window  closing  end  of  tube;  C,  handle;  D,  cords  connecting  in- 
strument with  battery;  E,  inflating  apparatus;  E,  main  tube  of  procto- 
scope. 

lent  description  of  it  given  in  his  book  on  the  "  Diseases  of  the 
Anus,  Rectum,  and  Pelvic  Colon." 

"  This  instrument  is  composed  of  a  large  cylinder  (F)  into 
one  part  of  the  circumference  of  which  is  fitted  a  small  metallic 
tube,  closed  by  a  flint-glass  bulb  at  its  distal  end.  The  electric 
lamp  is  fitted  upon  a  long  metallic  stem,  and  carried  through 


900  THE    GASTRO-INTESTINAL    CLINIC 

the  small  cylinder  to  the  end  of  the  instrument,  as  is  shown  in 
the  illustration. 

"  The  proctoscope  is  introduced  through  the  anus  with  the 
obturator  (A)  in  position.  As  soon  as  the  internal  sphincter  is 
passed,  this  obturator  is  withdrawn  and  the  bayonet-fitting 
ptug  (B),  which  contains  either  a  plain  glass  window,  or  a  lens 
focused  to  the  length  of  the  instrument  to  be  used,  is  inserted 
in  the  proximal  end  of  the  instrument.  This  plug  is  ground  to 
fit  air-tight,  and  thus  closes  the  instrument  perfectly.  The  plug 
being  inserted  in  the  tube,  a  very  slight  pressure  upon  the 
hand-bulb  will  cause  inflation  of  the  rectal  ampulla  to  such  an 
extent  that  the  whole  rectum  can  be  observed,  and  the  instru- 
ment can  be  carried  up  to  the  promontory  of  the  sacrum  with- 
out coming  in  contact  with  the  rectal  wall.  Further  dilata- 
tion will  show  the  direction  of  the  canal  leading  into  the  sig- 
moid, and  by  a  little  care  in  manipulating  the  instrument,  and 
keeping  the  gut  well  dilated  in  advance,  it  can  be  carried  up 
into  this  portion  of  the  intestine  without  the  least  traumatism 
of  the  parts.  If  any  fecal  material  obscures  the  light  by  being 
massed  or  smeared  over  the  glass  bulb,  the  plug  can  be  re- 
moved, and  a  pledget  of  .cotton  introduced  with  a  long  dress- 
ing-forceps, to  wipe  this  off,  so  that  the  plug  can  be  reintro- 
duced and  the  examination  continued  with  very  slight  delay  or 
inconvenience. 

"  The  adjustable  handle  (  C)  fits  on  the  rim  of  the  instrument 
and  thus  converts  it  into  a  Kelly  tube.  This  instrument  is  oper- 
ated with  an  ordinary  dry  battery  of  four  cells." 

In  the  following  pages  the  more  frequent  rectal  diseases  will 
be  briefly  discussed.  It  is  not  intended  to  review  all  the  ac- 
cepted operative  procedures,  but  rather  to  indicate  such  surgical 
and  medical  treatments  as  may  be  carried  out  in  the  office  of 
the  general  practitioner  or  in  the  patient's  home.  The  methods 
indicated  are  such  as  may  be  applied  to  that  large  class  of  pa- 
tients who  either  will  not  or  cannot  be  treated  in  a  hospital. 


DISEASES    OF    THE    RECTUM    AND   ANUS  QOI 

THE  RECTAL  RELATIONS  OF  CONSTIPATION 

The  causes  of  constipation  are  either  general,  depending 
upon  some  abnormal  state  of  the  digestion,  obstruction  of  the 
bowel,  or  disease  in  some  portion  of  it ;  or  local,  resulting  from 
some  anomalous  anatomic  condition  of  the  rectum,  or  upon 
pathologic  processes  in  or  about  it.  The  general  or  digestive 
conditions  causing  constipation  have  been  fully  discussed  in 
Lectures  LXIX.  and  LXX.,  so  that  the  local  rectal  factors  only 
will  be  considered  here. 

Anatomically,  constipation  or  obstipation  may  be  caused  by 
an  abnormal  formation  of  the  rectal  valves,  as  pointed  out  by 
Martin  of  Cleveland,  who  has  done  much  to  clear  up  the  aeti- 
ology of  these  conditions. 

A  frequent  local  cause  of  constipation  is  an  abnormal  ir- 
ritability of  the  sphincter  muscles,  causing  a  loss  of  the  nor- 
mal relation  between  the  expulsive  power  of  the  rectum  and 
the  cut-off  action  of  the  sphincters.  Congestion  or  inflamma- 
tion of  the  rectum  or  anal  tissues  causes  an  increased  irrita- 
bility of  the  sphincter  muscles  due  to  excitation  of  the  nerves 
supplying  those  organs ;  thus  we  frequently  find  constipation  as 
a  symptom  in  cases  of  internal  hemorrhoids,  external  hemor- 
rhoids, fissures,  abscesses,  or  ulceration  of  the  rectum.  Pros- 
tatic congestion  and  hypertrophy  are  often  important  factors. 
Other  cases  are  due  to  local  obstruction,  as  in  benign  or  ma- 
lignant stricture,  or  the  presence  of  tumors  or  foreign  bodies 
in  or  about  the  rectum.  In  women,  the  pressure  upon  the 
rectal  wall  of  an  enlarged  uterus,  or  tumors  connected  with 
the  uterus,  forms  a  very  troublesome  complication  when  we  try 
to  relieve  this  condition.  There  are  also  some  cases  in  which 
the  constipation  is  due  to  paralysis  or  loss  of  tone  on  the  part 
of  the  rectal  and  accessory  muscles  of  defecation. 

The  Operation  of  Divulsion. — One  of  the  most  efficient 
means  of  treating  these  spasmodic  cases  is  the  employment  of 
divulsion  or  rapid  dilatation  of  the  sphincter  under  g-eneral 
anaesthesia.     Rapid  divulsion  is  of  value  from  the  fact  that 


902  THE    GASTRO-INTESTINAL    CLINIC 

the  nerves  supplying  the  muscles  undergo  the  process  of  nerve 
stretching,  thereby  lessening  the  irritability  and  improving 
the  venous  and  arterial  circulation  of  the  muscle. 

N^  it  rolls  oxide  has  many  advantages  over  other  anaesthetics 
for  this  purpose,  as  the  sphincteric  reflexes  are  retained, 
thereby  furnishing  an  index  as  to  the  amount  of  force  re- 
quired. The  operation  can  be  as  readily  performed  under 
ethyl  chloride  anccsthesia,  the  tubes  of  ethyl  chloride  being  very 
convenient  to  carry  in  the  emergency  case.  Divulsion  should 
be  manual  and  not  instrumental,  thereby  avoiding  the  danger 
of  undue  laceration  of  the  muscle.  .  The  sphincter  should  be 
stretched  to  its  utmost,  till  the  fibers  just  begin  to  give  way, 
care  being  taken  not  to  tear  the  muscle.  This  operation  need 
not  confine  the  patient  to  bed,  but  may  be  performed  in  the 
office. 

When  any  extensive  surgical  operation  is  to  follow,  the 
divulsion  should  be  performed  under  the  influence  of  ether  or 
chloroform,  bearing  in  mind  that  the  reflexes  are  then  absent; 
therefore  much  more  care  and  time  are  recjuired  in  the  per- 
formance of  the  operation. 

Under  nitrous  oxide  or  ethyl  chloride,  a  good  divulsion  can 
be  obtained  in  from  thirty  to  fifty  seconds,  while  under  the 
other  anaesthetics  several  minutes  should  be  consumed  in  care- 
fully kneading  the  muscle  until  it  is  thoroughly  relaxed,  very 
little  force  being  employed.  In  about  70  per  cent,  of  cases 
suffering  with  rectal  troubles  and  constipation  as  a  symptom, 
divulsion  and  appropriate  treatment  of  the  local  conditions 
will  completely  cure  the  constipation. 

It  may  be  well  to  add  that  the  stretching  of  the  muscle  in 
itself  will  in  nearly  every  case  relieve  any  local  pain  in  or 
about  the  rectum,  and,  from  the  improvement  in  the  circula- 
tion, materially  hasten  the  cure  in  the  majority  of  cases.  "Di- 
vulsion is  indicated  in  all  cases  where  there  is  marked  inflam- 
mation, strangulation,  pain,  or  hemorrhage  of  the  rectum,  the 
only  contra-indications  being  paralysis  of  the  sphincters  and 
malignant  disease  situated  near  the  anal  orifice. 


DISEASES    OF   THE    RECTUM    AND  ANUS  9^3 

FECAL    IMPACTION 

Impaction  of  feces  in  the  rectum  may  be  due  to  catarrhal 
conditions  of  the  colon,  muscular  atony  giving  rise  to  sluggish 
peristalsis,  dilatation,  and  sacculation  particularly  of  the  sig- 
moid and  rectum,  and  arrested  foreign  bodies  in  the  bowel, 
such  as  seeds.  Should  the  feces  become  stopped  at  any  por- 
tion of  the  colon,  the  watery  constituents  are  absorbed,  leaving 
a  firm  residue,  rich  in  lime  salts,  glued  together  by  mucus  and 
the  compressing  muscular  action  of  the  bowel.  This  mass 
shows  a  marked  tendency  to  adhere  to  the  walls  of  the  gut,  and 
may  produce  considerable  local  irritation,  followed  in  some 
cases  by  ulceration  and  hemorrhage. 

The  early  symptoms  are  constipation,  partial  or  absolute, 
followed  suddenly  by  diarrhea.  The  stools  are  liquid  and  fre- 
quent, with  a  marked  tendency  to  tenesmus.  If  the  condition  is 
pronounced,  there  may  be  considerable  auto-intoxication,  with 
flatulence  and  a  sense  of  abdominal  fullness.  Should  the  im- 
paction be  in  the  sigmoid,  palpation  may  reveal  a  doughy 
tumor  in  the  left  groin,  with  tympanites  over  the  colon 
above. 

In  the  rectum,  the  mass  can  usually  be  felt  upon  digital  ex- 
amination. Pain  in  the  back,  rectum,  and  anus  is  a  frequent 
symptom.  The  diarrhea  is  caused  by  irritation  of  the  mucous 
membrane  inducing  an  excessive  production  of  mucus.  Added 
to  this,  the  liquid  contents  of  the  bowel  above  the  impaction 
may  insinuate  themselves  along  the  side  of  the  fecal  mass  or,  in 
a  few  instances,  may  make  a  canal  directly  through  it,  and  thus 
pass  down  the  alimentary  canal.  If  there  is  any  ulceration,  the 
stool  will  be  tinged  with  blood. 

The  treatment  of  impaction  consists  in  the  removal  of  the 
arrested  fecal  mass,  followed  by  treatment  of  the  irritation  of 
the  mucosa  from  the  unavoidable  -traumatism,  and  finally,  the 
correction  of  the  primary  cause,  if  this  be  a  colitis  or  atony  of 
the  muscular  coats  of  the  bowel. 

Where  the  feces  are  lodged  in  the  rectum,  a  divulsion  may  be 


904  THE    GASTRO-IXTESTINAL    CLINIC 

performed,  when  the  mass  can  be  turned  out  with  the  fingers 
or  broken  up  and  removed  with  a  rectal  scoop.  If  the  collec- 
tion is  in  the  sigmoid,  or  is  too  large^^or  too  hard  to  remove 
through  the  anus,  Tuttle  advises  an  injection  of  ^  pint  of 
warm  water,  to  which  has  been  added  3  ilof  inspissated  ox-gall 
and  3  i  of  glycerin.  This  should  be  retained  as  long  as  pos- 
sible, and  repeated  four  times  in  tw^enty-four  hours.  The  mass 
will  then  usually  be  soft  enough  to  pass  the  anus  after  a  large 
enema,  associated,  if  necessary,  with  a  large  dose  of  castor 
oil. 

Dilatation  of  the  rectum  and  colon  with  air,  either  by  means 
of  the  pneumatic  proctoscope  or  a  simple  rubber  valve  syringe, 
will  frequently  assist  in  dislodging  the  impaction,  especially 
when  assisted  by  gentle  massage  of  the  abdomen  over  the 
tumor.  After  the  rectum  has  been  emptied,  the  patient  should 
be  given  a  laxative,  preferably  castor  oil  or  magnesium  sul- 
phate, followed  by  the  internal  administration  of  such  peri- 
staltic stimulants  as  eserine  or  strychnine. 

The  patient  should  make  a  daily  practice  of  drinking  plenty 
of  water  and  taking  regular  exercise.  Should  any  symptoms 
of  constipation  again  appear,  relieve  the  bowels  with  a  saline 
laxative. 

Should  there  be  any  local  ulceration  in  the  rectum  or  sig- 
moid, it  will  usually  yield  to  a  daily  irrigation  with  warm 
normal  salt  solution.  This  injection  will  often  relieve  the  con- 
dition of  shock  which  sometimes  follows  the  rapid  removal  of 
the  retained  feces  and  gas.  Internally,  ichthyol,  grns.  5,  three 
times  daily,  seems  to  exert  a  very  soothing  effect  on  irritations 
in  the  upper  portion  of  the  colon. 

HEMORRHOIDS 

Varieties. — Hemorrhoids  may  be  classified  as  either  external 
or  internal,  depending  upon  whether  they  have  their  origin 
below  or  above  the  external  sphincter.  Of  the  external,  there 
are  practically  only  two  varieties,  the  thrombotic  pile,  consist- 
ing of  a  clot  of  blood  in  one  of  the  inferior  hemorrhoidal  veins. 


DISEASES    OF    THE    RECTUM    AND   ANUS  QOS 

or  else  a  clot  resulting  from  the  rupture  of  one  of  these  veins 
just  beneath  the  skin.  These  are  easily  recognized  by  their 
purple  color  and  shot-like  hardness  to  the  touch.  The  simplest 
and  most  effective  treatment  for  this  condition  is  to  inject  a 
few  drops  of  a  2  per  cent,  solution  of  cocain,  transfix  the  clot 
with  a  curved  bistoury,  turn  it  out,  stop  bleeding  by  pressure 
forceps,  or  by  torsion,  and  pack  the  cavity  with  iodoform  gauze 
kept  in  place  by  a  T  bandage.  Healing  will  be  complete  in  a 
few  days.  The  practice  of  using  sutures  in  or  around  the  anus 
and  rectum  is  to  be  condemned,  except  under  the  most  ideal 
aseptic  conditions,  and,  even  then,  infection  along  the  line  of 
suture  is  very  apt  to  take  place,  resulting  inevitably  in  the 
formation  of  a  fistula. 

The  second  variety  of  external  hemorrhoids  may  be  classi- 
fied as  hypertrophies  of  the  anal  margin.  These  may  be  either 
inflamed,  oedematous,  or  composed  principally  of  connective 
tissue.  For  the  inflamed  and  oedematous  varieties,  a  simple  di- 
vulsion  of  the  sphincters,  followed  by  the  application  of  hot 
compresses  for  ten  minutes  at  intervals  of  two  hours, .  will 
usually  result  in  almost  immediate  relief.  The  folds  rapidly 
decrease  in  size,  and  if  necessary  they  can  be  scissored  off 
under  local  anaesthesia  at  some  subsequent  period.  The  con- 
nective-tissue variety  rarely  give  any  trouble,  and  may  be  dis- 
regarded unless  they  become  inflamed,  when  they  should  be 
treated  as  the  preceding. 

Internal  hemorrhoids  may  be  classified  under  the  following 
five  vafieties,  thrombotic,  being  merely  a  clot  in  a  superior 
hemorrhoidal  vein ;  varicose,  or.  venous,  being  a  varicosity  of 
the  primary  branches  of  the  superior  hemorrhoidal  veins ;  the 
arterial,  which  are  relatively  rare;  the  capillary,  which  are 
small  piles  composed  of  enlarged  venous  and  arterial  capil- 
laries and  bleed  upon  the  slightest  touch  ;  and  the  Hhrous  hemor- 
rhoid, or  polypoid  pile;  this  last  variety  being  simply  a  vari- 
cose pile  which,  from  repeated  attacks  of  irritation  and  in- 
flammation, has  hypertrophied,  resulting  in  the  deposition  of 
an  excess  of  fibrous  tissue.     The  mucous  membrane  on  the 


906  THE   GASTRO-INTESTINAL    CLINIC 

surface  has,  from  this  irritation,  undergone  a  polypoid  degen- 
eration, and  as  a  result  there  may  be  a  profuse  discharge  of 
mucus  from  the  pile. 

The  symptoms  of  the  thrombotic  variety  are  pain  in  the 
rectum  coming  on  suddenly,  usually  after  some  straining  at 
stool,  accompanied  by  a  sense  of  fullness  or  a  feeling  as  of  a 
foreign  body  in  the  rectum.  Generally  there  is  considerable 
sphincterismus,  accompanied  by  constipation.  The  clot  can 
easily  be  felt  upon  digital  examination,  usually  just  at  the 
upper  border  of  the  internal  sphincter.  The  treatment  con- 
sists in  divulsion  of  the  sphincter  and  turning  out  of  the  clot 
after  transfixing  it  with  a  long,  curved  bistoury.  An  applica- 
tion of  stick  nitrate  of  silver  will  usually  stop  what  little  bleed- 
ing is  present,  or  the  cavity  may  be  packed  with  a  small  pledget 
of  cotton  saturated  with  adrenaline  chloride,  i-iooo.  The 
treatment  may  easily  be  performed  through  the  small  conical 
speculum  and  local  anaesthesia  is  rarely  necessary,  as  the  rectal 
mucosa  above  the  sphincter  is  not  very  sensitive.  A  5-grain 
iodoform  suppository  may  be  used  after  bowel  movements,  and 
one  may  be  inserted  at  bedtime  for  a  few  days.  The  bowels 
should  be  moved  every  day,  with  the  aid  of  a  mild  laxative  if 
necessary. 

Varicose  and  capillary  hemorrhoids  produce,  as  prominent 
symptoms,  bleeding  at  stool,  a  sense  of  fullness  at  stool,  consti- 
pation, and,  in  the  more  advanced  cases  of  the  varicose  variety, 
protrusion  of  the  piles,  which  may  reduce  themselves  sponta- 
neously or  may  have  to  be  replaced  manually.  Should  these 
hemorrhoids  not  be  replaced  immediately,  and  spasm  of  the 
sphincters  occur,  strangulation  is  almost  sure  to  follow,  at- 
tended with  great  pain,  swelling,  or  oedema  of  the  anal  margin, 
and,  in  some  cases,  sloughing  of  the  rectal  or  anal  tissues. 
Some  of  the  more  aggravated  cases  are  complicated  by  the 
formation  of  a  submucous  or  marginal  abscess.  If  the  pa- 
tient refuses  any  cutting  operation,  by  far  the  cjuickest  means 
of  relieving  the  symptoms  is  by  immediate  divulsion  under 
nitrous  oxide,  followed  by  the  application  of  hot  compresses. 


DISEASES    OF    THE    RECTUM    AND   ANUS  90/ 

The  case  may  subsequently  be  treated  either  palhatively  or  by 
the  injection  method. 

The  Injection  Treatment  of  Hemorrhoids This  has  in  the 

past  been  brought  into  disrepute  because  employed  by  quacks 
and  physicians  unacquainted  with  the  proper  techinque  and 
unable  to  cope  with  the  complications  resulting  from  improper 
methods.  In  the  experience  of  the  writer,  it  is  not  only  a 
safe  procedure,  but  the  results  obtained  earn  for  it  a  position 
as  a  recognized  and  satisfactory  method  of  treatment.  Its  ad- 
vantages consist  in  the  fact  that  the  patient  is  not  confined  to 
bed,  the  treatment  is  practically  painless,  the  complications  are 
few,  and  the  results  compare  very  favorably  with  those  follow- 
ing other  operative  methods.  Recurrences  are  rare,  and  when 
they  do  occur  it  is  usually  in  a  segment  of  the  rectum  not  pre- 
viously treated.  It  is  always  wise,  before  attempting  to  inject 
internal  hemorrhoids,  to  preface  the  treatment  with  a  thorough 
divulsion  under  nitrous  oxide,  thereby  removing  any  abnormal 
irritability  of  the  sphincters  which  may  exist.  Many  of  the 
accidents  which  have  been  reported  are  the  result  of  neglecting 
this  simple  procedure. 

The  solution  used  for  injection  is  a  matter  of  great  im- 
portance. The  use  of  the  stronger  solutions  will,  in  most 
instances,  be  followed  by  the  formation  of  a  slough,  causing 
considerable  pain  and  often  resulting  in  quite  serious  ulcera- 
tion, if  unrecognized  and  untreated. 

The  solutions  I  usually  employ  are  50  per  cent,  aqueous  so- 
lutions of  Phenol  Sodique  or  Phenol  Boboeuf,  filtered  and 
freshly  prepared.  Dr.  Tuttle  recommends  the  following 
formula,  which  he  attributes  to  Shuford : 

^  Ac.  carbolic  (Calvert's) , 3  ii 

Ac.  salicylici , 3  ss 

Sodii  biborat 3  i 

Glycerinae  (sterile) q.  s.  ad  f  i 

An  ordinary  all-metal  hypodermic  syringe,  with  a  three-inch 
extension  barrel,  may  be  used  for  the  injection. 

The  conical  speculum  should  be  introduced  and  the  hemor- 


908  THE    GASTRO-INTESTINAL    CLINIC 

rhoid  to  be  injected  prolapsed  into  it.  Firm  pressure  of  the 
end  of  the  speculum  is  then  made  against  the  lateral  wall, 
thereby  limiting  the  spread  of  the  solution  through  the  sur- 
rounding tissue.  The  hemorrhoid  is  then  swabbed  off  with  a 
2  per  cent,  solution  of  creolin.  From  three  to  ten  minims  of 
the  injection  solution  should  be  injected  directly  into  the  center 
of  the  pile,  the  amount  depending  upon  the  size  of'  the  tumor. 
The  speculum  should  be  withdrawn  first,  followed  by  the 
hypodermic  syringe.  Insert  a  5-grain  iodoform  suppository. 
Only  one  tumor'should  be  injected  at  a 'time,  and  an  interval 
of  from  five  to  seven  days  should  be  allowed  between  treat- ' 
ments.  Very  little  discomfort  follows  the  injection,  but  if  too 
much  fluid  is  used  a  slough  may  be  produced.  This  is  usually 
limited,  and  should  be  treated  by  an  application  oi  stick  nitrate 
of  silver,  followed  by  the  regular  use  of  iodoform  or  ichthyol 
suppositories.  No  further  treatment  should  be  instituted  until 
the  slough  has  healed.  The  fibrous  or  pol3^poid  hemorrhoid 
would  better  be  removed  by  excision,  as  the  injection  method 
usually  fails  to  cure  it  and  only  results  in  sloughing,  which 
later  causes  the  patient  considerable  discomfort.  The  pa- 
tient's bowels  should  be  kept  perfectly  regular  all  through  the 
treatment. 

When  a  patient  will  submit  to  an  operation  under  general 
anaesthesia  the  ligation  or  clamp  and  cautery  method  may  be 
resorted  to,  as  the  results  obtained  are  very  much  quicker,  al- 
though I  -do  not  believe  they  are  much  superior  to  those  ob- 
tained by  injection,  if  the  latter  be  skillfully  performed  under 
proper  antiseptic  conditions.  The  technic|ue  of  the  operative 
methods  may  be  obtained  from  any  of  the  standard  text-books 
on  rectal  diseases. 

The  crushing  method  for  the  treatment  of  hemorrhoids  is 
now  rarely  employed,  as  it  possesses  no  advantages  over  the 
clamp  and  cautery  or  ligature  operations.  The  Whitehead 
operation  of  excision  of  the  pile-bearing  area,  wbile  it  has 
given  brilliant  results  in  the  hands  of  a  few  surgeons,  has  so 
frequently  been  followed  by  stricture,  when  used  by  some  less 


DISEASES    OF    THE    RECTUM    AND   ANUS  909 

skillful  operator,  that  the  sooner  it  is  relegated  to  medical  liter- 
ature the  better. 

A  Palliative  for  Bleeding. — Should  the  patient  refuse  to 
have  any  of  the  above  methods  of  treatment  used,  great  relief 
may  be  given  in  cases  of  bleeding  by  the  use  of  the  following 
suppository : 

R  Pulv.  suprarenal.  ) 

Iodoform  S      • grn.xxxvi 

Ichthyol i?i  xxiv 

01.  theobrom q.  s. 

M.  ft.  suppos.  No.  12. 

Sig.     One   suppository  half  an  hour  before  bowels  are  to  be 
moved  and  one  after  movement. 

.The  morning  evacuation  may  be  rendered  more  comfortable 
by  the  injection  of  from  ^  to  i  oz.  of  olive  oil  into  the  rectum 
just  before  retiring,  retaining  it  overnight.  In  case  there  is 
strangulation,  the  piles  should  be  replaced  as  soon  as  possible. 
Should  there  be  much  difficulty  in  this,  the  application  of  a 
compress  wrung  out  of  very  hot  water  and  pressed  firmly 
against  the  inflamed  mass  of  tumors  will  usually,  in  about  ten 
minutes,  reduce  the  congestion  enough  to  allow  them  to  be 
reduced. 

FISSURE   OF  THE   ANUS 

This  frequent  and  painful  affection  is  often  a  complication 
of  internal  hemorrhoids,  but  may  also  exist  with  no  other 
condition. 

Symptoms. . — The  patient  presents  himself  with  a  history  of 
pain  beginning  after  stool  and  lasting  anywhere  from  a  few 
minutes  to  several  hours,  often  so  severe  as  to  incapacitate  him 
from  business.  There  may  be  more  or  less  constipation  oc- 
casioned by  the  excessive  spasm  of  the  sphincters.  Bleeding  is 
usually  slight,  except  when  complicated  by  some  other  condi- 
tion, such  as  hemorrhoids  or  deep  ulceration.  Examination 
shows  an  anus  tightly  contracted,  more  from  excessive  spasm 
than  hypertrophy.  At  the  posterior  margin  of  the  anus  there 
is  often  a  small  hypertrophied  skin  tab  or  sentinel  pile,  above 


910  THE    GASTRO-INTESTINAL    CLINIC 

which,  Upon  separating  the  buttocks  and  having  the  patient  bear 
down,  the  fissure  wih  be  seen  as  a  small  crack  in  the  posterior 
aspect  of  the  anus.  Upon  an  examination .  with  a  speculum 
the  fissure  will  prove  to  be  an  oval  ulcer,  sometimes  having 
ragged  indurated  edges.  At  times  in  the  upper  angle  of  this 
ulcer  a  minute  polypoid  fold  of  mucous  membrane  may  be 
found.  Care  should  be  exercised  to  be  sure  that  there  is  no 
sinus  in  the  base  of  the  fissure  leading  into  a  submucous  ab- 
scess. 

Treatment — Immediate  relief  of  the  symptoms  will  be  ob- 
tained by  a  thorough  divulsion  of  the  sphincter.  Subsequently, 
the  removal  of  the  sentinel  pile  and  superior  sentinel  polypoid 
fold,  under  local  anaesthesia,  followed  by  a  few  applications  of 
nitrate  of  silver,  will  suffice  to  make  a  perfect  cure. 

PRURITUS   ANI 

Probably  no  class  of  cases  gives  the  physician  or  specialist 
so  much  anxiety  and  annoyance  as  do  those  in  which  the  pre- 
dominant symptom  is  an  intolerable  itching.  Beginning  as  the 
consequence  of  rectal  or  anal  lesions,  such  as  external  or  in- 
ternal hemorrhoids,  or  as  the  result  of  irritating  discharges, 
the  anal  skin  becomes  so  changed  from  irritation  and  scratch- 
ing that  it  takes  on  a  characteristic  appearance  and  pathologic 
formation,  being  sometimes  even  eczematous  in  type,  which 
persists  after  the  primary  cause  has  been  removed. 

Symptoms — The  anal  skin  in  well-advanced  cases  is  much 
thickened,  friable,  cracked,  and  lacking  in  vitality.  It  looks 
leathery  and  full  of  creases  and  has  been  classically  described 
as  a  *'  washerwoman's  "  skin.  The  itching  is  generally  worse 
at  night  just  after  retiring,  and  the  patient  often  wakes  to  find 
that  he  has  been  scratching  vigorously  at  his  anus. 

Treatment — In  treating  these  cases  careful  attention  to  the 
diet  must  be  given  in  those  instances  where  there  is  an  under- 
lying condition  of  diabetes  mellitus,  Bright's  disease,  or  a 
rheumatic  diathesis.     The  local  cause  should  be  removed  and 


DISEASES    OF    THE    RECTUM    AND    ANUS  QH 

applications  should  be  made  to  the  skin,  not  only  to  relieve  the 
itching,  but  to  try  to  bring  the  skin  back  to  a  normal  condition. 
Applications  of  nitrate  of  silver  or  pure  carbolic  acid  should 
be  applied  to  the  fissured  skin,  followed  by  a  moderately  stim- 
ulating but  not  irritating  ointment.  Adler  recommends  a 
dressing  of  citrine  ointment,  full  strength  or  diluted  as  the 
case  may  recjuire.  Carbolated  petrolatum  or  acetanilid  oint- 
ment, 3  ss.  to  the  ounce,  may  relieve  the  itching.  Resin  cerate 
will  sometimes  be  found  valuable.  Where  the  skin  is  intoler- 
ant to  ointments  a  wash  of  dilute  alcohol,  lo  per  cent.,  or  5  per 
cent.  Labarraque's  solution,  may  be  tried.  A  few  cases  have 
been  relieved  by  the  following: 

i^  Menthol gr.  xx 

Alcohol q.  s. 

01.  cadini  \ 

01.  rusci    haa .m.  x. 

Ichthyol    ) 

Petrolat q.  s.  ad  §i 

M.  ft.  ung. 

Sig.     Apply  locallj'-. 

Internally  ichthyol,  given  over  a  long  period  of  time,  has  often 
brought  about  a  decided  improvement.  Acetate  of  potash  or 
sodium  bicarbonate  in  large  doses  has  proved  of  value.  Even 
in  the  worst  type  of  pruritus  sticking  faithfully  at  it,  by  both 
doctor  and  patient,  will  nearly  always  be  rewarded  by  a  cure 
or  at  least  a  very  gratifying  improvement. 

ABSCESS 

Varieties. — Abscess  in  the  neighborhood  of  the  anus  and 
rectum  is  of  such  frequent  occurrence,  and  early  treatment  so 
imperative,  that  the  condition  is  one  of  the  most  important  with 
which  we  have  to  deal.  The  most  common  varieties  are  the 
marginal  or  subcutaneous  abscess  of  the  edge  of  the  anus ;  the 
submucous,  found  in  the  rectum  and  upper  portion  of  the  anus ; 
the  perirectal,  situated  above  the  sphincter  in  the  cellular  tissue 
surrounding  the  rectum ;  and  the  ischiorectal^  occupying  the 
ischiorectal  fossa. 


912  THE    GASTR0-INTE3TINAL    CLINIC 

The  infection  may  either  start  at  the  skin  surface  or  may 
have  its  origin  from  pyogenic  material  within  the  rectum  and 
carried  to  the  point  of  inflammation  by  the  lymphatics  or  blood 
current.  Abscess  within  the  rectum  frequently  follows  infec- 
tion from,  strangulated  and  sloughing  hemorrhoids,  neglected 
fissures,  ulceration,  strictures,  both  benign  and  malignant,  and 
perforation  by  foreign  bodies,  such  as  fish  bones  or  pieces  of 
toothpick,  that  have  been  carelessly  swallowed. 

The  marginal  abscess  usually  follows  the  infection  of  ex- 
ternal hemorrhoids,  particularly  the , thrombotic  variety.  The 
ischiorectal  abscess  may  be  produced  by  traumatism  followed 
by  infection  from  the  bowel  through  the  lymphatics.  The  part 
which  tuberculosis  pla3'S  in  these  cases  I  feel  sure  has  been 
overestimated,  for  by  far  the  greater  number  of  cases  occur  in 
persons  previously  healthy,  and  after  cure  they  regain  their 
previous  good  health. 

The  symptoms  of  marginal  and  ischiorectal  abscesses  are 
pain  of  throbbing  character  near  the  anus,  localized  swelling 
and  redness  of  the  skin,  tenderness  upon  pressure,  and  indura- 
tion over  the  affected  area,  followed  by  fluctuation  and  a  dis- 
charge of  pus  if  the  abscess  opens  spontaneously.  There  may 
or  may  not  be  a  general  feeling  of  malaise,  attended  with  a 
temperature  of  septic  type.  In  the  ischiorectal  variety  there 
may  be  a  rapid  loss  of  weight  and  strength,  leading  to  a  mis- 
taken diagnosis  of  tubercular  complications.  The  submucous 
and  perirectal  abscesses  are  attended  with  pain  in  the  rectum 
or  anus  (worse  during  stool),  tenesmus,  constipation,  and  lo- 
calized tenderness  and  induration  upon  digital  examination. 
If  the  abscess  has  ruptured  into  the  rectum  there  is  a  decided 
relief  from  pain,  attended  with  the  free  discharge  of  pus  at 
stool. 

It  may  he  accepted  as  an  axiom  that  all  fistulas  in  the  neigh- 
borhood of  the  anus  or  rectum  are  the  direct  result  of  ab- 
scesses zuhich  have  been  eitlier  neglected  or  improperly  treated. 
Were  these  abscesses  radically  treated,  fistulas  would  rarely 
occur. 


DISEASES    OF    THE    RECTUM    AND    ANUS  9I3 

Diagnosis  of  Ischiorectal  Abscesses. — These  may  be  recog- 
nized by  tenderness  over  the  ischiorectal  fossa,  swelling,  in- 
duration, and  redness  on  either  side  of  the  anal  margin.  If 
pus  be  present,  fluctuation  may  be  obtained  by  bimanual  pal- 
pation with  one  finger  introduced  into  the  rectum.  The  ab- 
scess may  have  ruptured  spontaneously  either  upon  the  skin 
surface  or  into  the  bowel,  in  which  last  case  the  opening  will 
usually  be  found  in  the  inten^al  between  the  two  sphincters. 

Treatment  of  Ischiorectal  Abscess. — Every  ischiorectal  ab- 
scess should  be  incised  immediately  to  prevent  the  foiTnation  of 
a  fistula.  Do  not  waste  time  in  abortive  treatment,  incise 
freely  and  drain.  The  method  I  find  most  useful  is  to  thor- 
oughly anaesthetize  the  area  for  operation  by  a  hypodermic  in- 
jection of  a  2  per  cent,  solution  of  cocain,  and,  with  a  curved 
bistoury,  transfix  the  swelling  in  its  long  axis,  carrying  the 
incision  well  into  the  healthy  tissue  at  either  end.  In  the  same 
manner  make  another  incision  in  the  middle  of  the  first,  and 
at  right  angles  to  it.  With  a  pair  of  curved  scissors  trim  off 
the  projecting  angles  of  tissue  left  by  this  crossed  incision,  thus 
converting  the  wound  into  a  diamond-shaped  cavity.  If  pos- 
sible, curette  out  the  necrotic  tissue  and  pack  the  cavity  tightly 
with  iodoform  gauze.  Over  this  place  a  pad  of  cotton  held  in 
place  by  a  T  bandage.  After  forty-eight  hours,  remove  pack- 
ing and  pack  loosely  with  plain  gauze  or  cotton  saturated  with 
acetanilid  ointment  3  ss.  to  o'l.  Usually,  it  is  not  necessary  nor 
desirable  to  put  the  patient  to  bed. 

The  Treatment  of  Complications. — When  there  is  much 
spasm  of  the  sphincters  they  should  be  divulsed  as  soon  as 
convenient.  Have  the  bowels  moved  regularly  after  the  pri- 
mary dressing  has  been  removed.  If  excessive  granulations 
develop,  they  should  be  cauterized  with  pure  nitrate  of  silver. 
Probe  the  wound  carefully  at  every  dressing,  and  should  any 
sinuses  be  found,  divide  them  freely  under  local  anaesthesia. 
Any  overhanging  edges  of  skin  which  persist  should  be  scis- 
sored off.  If  the  abscess  has  perforated  the  bowel,  there  should 
be  no  hesitancy  in  dividing  the  overlying  tissues,  especially  if 


9^4  THE    GASTRO-INTESTINAL    CLINIC 

the  external  sphincter  only  be  involved.  Divide  the  muscle 
fibers  at  right  angles,  so  as  to  prevent  a  possible  incontinence 
from  a  poorly  formed  cicatrix.  Particular  attention  should  be 
paid  to  the  after-treatment,  no  case  should  be  discharged  until 
every  part  of  the  wound  is  absolutely  healed.  If  done  under 
general  aneesthesia,  the  primary  operation  should  include  a 
careful  dissection  of  all  indurated  tissue  and  the  patient  should 
be  kept  in  bed  until  granulation  has  become  well  established. 

In  place  of  the  cocain  anaesthesia,  Gant  uses  sterile  water 
injected  intradermically.  As  soon  as  the  skin  is  thoroughly 
infiltrated  over  the  line  of  incision,  he  makes  subcutaneous  in- 
jections until  the  tissues  are  fully  distended.  He  claims  that 
the  advantages  of  this  method  are  rapid  anaesthesia  and  free- 
dom from  toxic  symptoms, 

FISTULA  IN  ANO 

As  mentioned  above,  the  formation  of  a  fistula  must  be 
secondary  to  an  abscess.  The  classification  into  complete,  in- 
complete, and  "  horseshoe  "  fistulas  may  be  accepted  for  con- 
venience' sake,  and  I  believe  the  terms  are  so  gener'ally  under- 
stood as  to  need  no  special  description.  The  variety  neces- 
sarily depends  upon  the  direction  in  which  the  pus  has  bur- 
rowed and  at  what  point  the  abscess  has  ruptured.  If  the  ab- 
scess has  only  opened  on  the  skin  surface,  the  result  will  be  an 
incomplete  external  fistula ;  if  into  the  bowel,  an  incomplete  in- 
ternal fistula;  if  in  both  places,  a  complete  fistula;  and  if  the 
pus  has  burrowed  around  the  outside  of  the  rectum,  the  natural 
consequence  would  be  the  formation  of  the  "  horseshoe " 
fistula. 

Diagnosis — The  presence  of  a  fistula  may  be  inferred  from 
the  history  of  an  abscess  followed  by  a  continuous  or  an  in- 
termittent discharge  of  pus  from  the  anus  or  skin  surface. 
Upon  examination  a  sentinel  papilla  or  button  of  granulation 
tissue  may  be  seen  near  the  anus.  Slight  pressure  will  cause 
a  drop  of  pus  to  be  squeezed  from  the  external  opening  of  the 


DISEASES    OF   THE    RECTUM    AND   ANUS  915 

fistula,  which  is  usually  in  the  center  of  the  papilla.  A  probe 
should  be  gently  and  carefully  passed  through  this  opening 
and  the  sinus  explored  to  find  if  an  internal  opening  exists. 
The  internal  opening  in  the  majority  of  cases  may  be  located 
in  the  interval  between  the  external  and  internal  sphincters. 
After  the  probe  is  in  place,  the  finger  may  be  inserted  into  the 
rectum,  when,  by  careful  palpation,  the  whole  fistula  may  be  out- 
lined. If  the  finger  is  introduced  before  the  probe  is  in  place, 
the  spasm  of  the  sphincter  will  prevent  the  probe  from  passing 
into  the  internal  opening. 

The  internal  incomplete  fistulas  are  usually  first  located  by 
digital  examination,  the  fistulous  tract  feeling  like  a  fibrous 
cord  beneath  the  finger.  A  bent  probe  may  then  be  passed 
through  a  speculum  and  into  the  opening  of  the  sinus. 

When  the  fistula  has  multiple  openings  and  branch  sinuses, 
they  should  all  be  carefully  outlined  before  operation.  The 
injection  of  peroxide  of  hydrogen  or  of  a  colored  solution  into 
a  fistula   will  often  aid  one  to  find  the  internal  opening. 

Treatment — The  recognized  methods  for  the  treatment  of 
fistula  are  the  application  of  cauterizing  agents,  the  elastic 
ligature,  incision,  and  excision,  followed  by  suture  of  the 
primary  wound..  The  use  of  caustics  or  absorbents  has  been  so 
universally  unsuccessful  that  it  has  justly  fallen  into  disrepute. 
The  operation  by  elastic  ligature,  aside  from  being  very  pain- 
ful, is  only  applicable  when  the  fistula  has  no  branch  sinuses, 
and  even  then  the  cures  are  few  and  far  between.  Excision  of 
the  fistulous  tract,  with  suture  of  the  wound,  is  only  successful 
under  the  most  perfect  aseptic  conditions,  and  because  of  the 
difficulty  of  obtaining  these  conditions  in  the  neighborhood  of 
the  rectum,  the  wound  often  becomes  reinfected  and  may  take 
on  conditions  more  serious  than  existed  before  the  primary 
operation.  One  disastrous  result  will  more  than-  counterbal- 
ance the  time  saved  over  the  more  conservative  method  of  free 
incision,  with  repair  by  granulation. 

A  Majority  of  Fistulas  Non-tubercular. — Many  authors  in- 
sist that  a  very  large  percentage  of  fistulas  is  of  tubercular 


91 6  THE    GASTRO-INTESTINAL    CLINIC 

origin.  While  this  may  be  true  of  cases  treated  in  hospital 
dispensaries,  it  is  certainly  not  true  in  respect  to  those  treated 
in  private  practice.  The  majority  of  fistulas  occur  in  persons 
otherwise  healthy,  while  only  about  12  per  cent,  are  associated 
with  or  followed  by  tuberculosis  of  the  lungs.  It  must  be  borne 
in  mind  that  a  tubercular  fistula,  and  a  fistula  in  a  tubercular 
subject,  are  two  entirely  different  conditions.  The  mere  pres- 
ence of  phthisis  pulmonalis  should  not  deter  one  from  operat- 
ing upon  a  fistula,  with  fair  chance  of  success,  except  in  cases 
where  this  fistulous  tissue  shows  localized  tubercular  infection. 
In  all  these  cases  it  is  of  great  advantage  to  employ  local  an- 
aesthesia, thereby  avoiding  any  possible  irritation  of  the  lung 
tissue  by  the  anaesthetic. 

In  most  cases  where  a  fistula  has  existed  for  any  length  of 
time,  there  will  be  found  an  excessive  irritability  of  the  sphinc- 
ters. Where  this  exists  it  is  well  to  preface  treatment  by  thor- 
ough divulsion  of  the  sphincter.  After  two  or  three  days'  rest 
the  skin  and  tissues  over  the  fistula  should  be  thoroughly  an- 
aesthetized with  a  2  per  cent,  solution  of  cocain.  A  grooved 
director  should  be  passed  through  the  fistula,  and  the  tissues 
above  divided  either  with  a  bistoury  or  sharp  scissors. 

In  place  of  a  grooved  director,  the  fistula  knife  shown  in 
cut  will  be  found  very  useful.  It  was  designed  by  Dr.  R.  W. 
Martin,  and  is  shaped  like  a  large  cataract  knife  with  a  flex- 


FiG.  102. — Martin's  fistula  knife. 

ible,  probe-pointed  beak.  The  probe  can  be  passed  through  the 
fistula,  and  then,  with  a -finger  introduced  into  the  rectum,  the 
end  can  be  bent  and  brought  out  through  the  anus.  The  over- 
lying tissues  can  then  be  divided  with  no  danger  of  slipping. 

If  there  are  any  other  sinuses,  these  should  be  laid  freely 
open.  In  dividing  the  sphincters,  be  careful  to  cut  the  fibers 
transversely.     Stop  any  bleeding  by  torsion  or  compression 


DISEASES    OF   THE    RECTUM    AND   ANUS  917 

with  liemostats,  pack  the  wound  tightly  with  iodoform  gauze, 
and  apply  a  pad  of  cotton  held  in  p.lace  by  a  T  bandage.  It  is 
not  necessary  in  most  cases  to  put  the  patient  to  bed,  but  he 
should  keep  c[uiet  for  the  first  twenty-four  hours.  At  the  end 
of  forty-eight  hours  remove  the  gauze,  clean  out  the  wound, 
and  dress  with  a  light  packing  of  plain  gauze  or  cotton  sat- 
urated with  acetanilid  ointment  3  i  to  oi-  Too  tight  a  packing 
will  prevent  the  formation  of  healthy  granulation.  Be  sure  to 
keep  the  granulations  in  check  by  the  application  of  pure  ni- 
trate of  silver  every  three  to  five  days.  Dress  the  wound  daily, 
and  carefully  probe  it  to  discover  if  any  sinuses  have  been  over- 
looked. If  any  are  found,  open  them  freely  under  local  an- 
esthesia. Incomplete  fistulas,  either  external  or  internal,  may 
have  to  be  made  complete  fistulas  and  freely  divided  before 
they  will  heal.  The  most  important  factor  in  curing  a  fistula 
is  to  obtain  free  drainage.  Do  not  allow  any  overhanging 
edges  of  skin  or  undivided  sinuses  to  persist,  as  they  will  only 
offer  a  field  for  reinfection.  Do  not  persist  in  packing  a  wound 
with  iodoform,  as  its  constant  use  causes  an  overstimulation  of 
the  granulations,  resulting  in  the  formation  of  a  poorly  nour- 
ished hard  cicatrix,  often  showing  a  pronounced  tendency  to 
contract. 

PROLAPSE  OF  THE  RECTUM 

By  prolapse  of  the  rectum  we  mean  any  protrusion  of  the 
rectum,  including  either  the  mucous  membrane  or  all  of  the 
coats  of  the  bowel,  through  the  anal  aperture.  Procidentia  is  a 
term  used  to  describe  a  prolapse  consisting  of  all  the  coats  of 
the  bowel.  A  slight  eversion  of  the  anal  mucous  membrane 
takes  place  at  every  stool,  which  may  be  considered  physiologic. 

.Etiology — The  causes  of  prolapsus  may  be  summed  up  as 
any  conditions  which  produce  an  abnormal  tension  on  the 
rectal  mucosa,  such  as  straining  at  stool  due  to  hemorrhoids, 
polypi,  stricture,  or  tenesmus  due  to  ulceration.  It  may  be 
produced  by  any  weakness  in  the  natural  pelvic  supports  of 
the  rectum  or  sigmoid,  particularly  where  there  is  an  elonga- 


91 8  THE    GASTRO-IXTESTIXAL    CLINIC 

tion  of  the  mesentery.  A  relaxed  condition  of  the  sphincters 
may  be  another  factor,  especially  that  found  in  old  age,  in 
paralysis,  and  after  operations  which  have  destroyed  the 
sphincteric  control.  In  some  very  pronounced  cases  there  will 
be  found  either  an  undeveloped  internal  sphincter  or  an  entire 
absence  of  that  organ. 

'  Symptoms. — These  cases  usually  have  a  history  of  gradually 
increasing  constipation,  followed  by  a  protrusion  from  the  anus, 
which  at  first  goes  back  spontaneously.  As  the  mass  increases 
in  size  the  patient  finally  has  to  reduce  it  after  every  stool.  The 
mucosa,  from  irritation,  becomes  enormously  hypertrophied, 
and  after  the  condition  has  become  pronounced,  the  constipa- 
tion is  followed  by  a  teasing  diarrhea  containing  much  mucus, 
which  is  sometimes  streaked  with  pus  and  blood.  In  exam- 
ining these  patients,  unless  the  mass  protrudes  spontaneously,  a 
full  enema  of  warm  water  should  be  administered,  so  that  the 
entire  prolapse  will  protrude  at  stool.  The  prolapse  will  then 
be  found  to  consist  of  a  hemispheric  tumor,  A-arying  in  size 
from  that  of  a  walnut  to  that  of  a  man's  fist,  depending  upon 
whether  the  prolapse  consists  of  mucous  membrane,  or  includes 
all  the  coats  of  the  bowel. 

The  opening  of  the  bov/el  is  usually  situated  about  in 
the  center  of  the  tumor,  and  may  appear  simply  as  a  slit,  or  it 
may  be  circular  in  outline.  The  mucous  membrane  is  thrown 
into  irregular  folds  which  surround  the  prolapse.  The  mucosa 
is  greatly  -hypertrophied,  and  is  often  covered  with  consider- 
able mucus. 

Treatment — After  examination  the  prolapse  should  be  care- 
fully reduced.  The  incomplete  variety  may  be  successfully 
treated  by  injections  in  the  same  manner  as  in  treating  in- 
ternal hemorrhoids,  care  being  taken  to  inject  the  solution  well 
under  the  mucous  membrane.  A  T  bandage  should  be  used 
during  the  first  stages  of  treatment  to  keep  the  prolapsed  part 
in  place.  If  a  polypoid  tumor  be  present,  this  should  be  re- 
moved before  any  other  treatment  is  tried.  When  the  prolapse 
is  due  to  hemorrhoids,  a  divulsion  of  the  sphincters  will  often 


DISEASES    OF    THE    RECTUM    AND    ANUS  9I9 

Stop    the    protrusion,    leaving    only    the    hemorrhoids    to    be 
treated. 

In  children,  prolapse  may  frequently  be  cured  by  strapping 
the  buttocks  together  with  adhesive  plaster.  The  child  should 
be  given  an  enema  of  warm  water  and  m.ade  to  have  its  bowel 
movement  while  lying  on  its  side.  Should  any  protrusion 
occur,  it  should  be  immediately  replaced. 

In  adults,  the  wearing  of  plugs  or  compresses  to  support  the 
anus  gives  only  temporary  relief,  and  eventually  aggravates 
the  condition. 

In  bad  cases  of  complete  prolapse,  nothing  but  a  radical  sur-. 
gical  operation  will  give  any  permanent  result.  Among  the  best 
operations  for  this  condition  may  be  mentioned  rectopexy,  or 
suspension  of  the  rectum  on  the  sacrum;  excision;  and  colo- 
pexy,  which  consists  in  anchoring  the  sigmoid  to  the  parietal 
peritoneum  and  abdominal  wall.  AMiere  the  prolapse  is  not  very 
extensive,  the  condition  may  be  treated  just  as  in  a  case  of 
hemorrhoids  operated  on  by  the  clamp  and  cautery  method. 
Linear  cauterization  has  been  beneficial  in  some  instances,  but 
the  results  are  rarely  permanent. 

For  the  technique  of  these  operations  you  are  referred  to 
the  larger  text-books  on  rectal  surgery.  They  should  never 
be  attempted  by  any  but  a  skilled  surgeon. 

STRICTURE   OF   THE   RECTUM 

Varieties  and  Etiology. — Stricture  of  the  rectum  may  be 
either  hereditary,  spasmodic,  inflammatory,  or  malignant.  The 
first  two  varieties  are  so  rarely  seen  that  the  inflammatory  kind 
will  be  the  only  one  considered.  Under  this  heading  may  be 
included  those  produced  by  simple  inflammatory  processes, 
syphilis,  and  tubercular  ulceration.  While  it  is  undoubtedly 
true  that  many  patients  suffering  from  stricture  of  the  rectum 
are  also  afflicted  with  syphilis,- yet  it  is  rarely  that  the  stricture 
cambe  directly  proved  to  be  caused  by  the  specific  infection ;  more 
often  the  beginning  of  the  trouble  can  be  traced  to  some  acute 


920  THE    GASTRO-INTESTINAL    CLINIC 

or  chronic  infection  involving  the  deeper  coats  of  the  bowel. 
Inflammation  of  the  mucous  membrane  alone  is  not  known  to 
be  followed  by  stricture,  as  it  is  probably  necessary  to  have 
the  submucous  and  muscular  coats  involved  before  this  process 
is  set  up.  The  primary  inflammation  is  followed  by  a  plastic 
exudate  beneath  the  mucosa  which  finally  becomes  organized 
or  transformed  into  fibrous  tissue,  and  it  is  the  secondary  con- 
traction of  this  fibrous  tissue  that  produces  the  stricture.  As- 
sociated with  the  stricture  we  nearly  always  have  ulceration  of 
the  mucous  membrane,  usually  most  pronounced  at  the  upper 
and  lower  margins  of  the  stricture,  and  accompanied  by  a  more 
or  less  copious  discharge  of  mucus  and  pus,  with  sometimes 
a  trace  of  blood.  If  the  ulceration  is  extensive,  very  serious 
hemorrhages  may  be  produced.  As  the  result  of  ulceration, 
submucous  abscesses  are  often  formed,  resulting  in  the  produc- 
tion of  one  or  more  fistulas. 

Symptoms — A  patient  afflicted  with  stricture  usually  gives 
a  history  of  a  preceding  rectal  inflammation,  with  more  or  less 
pronounced  symptoms,  such  as  pain,  diarrhea,  dysentery,  tenes- 
mus ;  with  the  presence  of  pus  or  blood,  followed,  after  the 
acute  symptoms  have  subsided,  by  a  gradually  increasing  con- 
stipation, until  finally  the  patient  has  to  rely  on  the  use  of  laxa- 
tives or  enemas  to  obtain  any  movement  of  the  bowels.  Oc- 
casionally, in  place  of  constipation  there  may  exist  a  constant 
teasing  diarrhea,  with  a  general  feeling,  as  Tuttle  describes  it, 
of  "  unfinished  business."  Along  with  the  obstructive  symp- 
toms, there  may  be  associated  those  of  ulceration  and  sup- 
puration. 

Diagnosis — If  the  stricture  is  in  the  lower  portion  of  the 
rectum,  the  diagnosis  can  be  made  by  digital  examination, 
while,  if  it  is  in  the  upper  rectum  or  sigmoid,  the  use  of  a  rectal 
bougie  or  proctoscope  maybe  necessary  to  confirm  the  diagnosis. 
Care  should  be  used  in  passing  any  instrument  through  the 
stricture,  not  to  use  any  force,  as  the  tissue  is  often  very  friable, 
and  much  damage  may  result. 

Treatment — The  radical  cure  of  stricture  of  the  rectum  is 


DISEASES    OF    THE    RECTUM    AND    ANUS  92 1 

often  so  disappointing  and  unsatisfactory  that  I  believe  we  are 
justified  in  adopting  a  very  conservative  course,  performing 
the  more  extensive  operations  only  after  all  other  expedients 
have  failed. 

Enemas,  especially  when  used  by  the  patient,  frequently  in- 
crease the  irritation  and  ulceration.  The  persistent  use  of 
saline  laxatives  often  increases  the  local  tenderness.  By  far 
the  most  effective  and  soothing  laxative  is  simple  castor  oil, 
and  the  sooner  the  patient  contracts  the  habit  of  using  it  the 
better. 

Many  of  the  symptoms  can  be  relieved  by  gradual  dilatation 
of  the  stricture  with  bougies,  especially  if  the  treatment  is  con- 
tinued for  a  long  period  of  time,  months  or  even  years.  The 
dilatation  should  be  practiced  once  or  twice  a  week,  and  after 
the  ulceration  has  been  controlled,  and  the  stricture  well  di- 
lated, the  periods  between  treatments  may  be  increased.  The 
application  of  pure  nitrate  of  silver  to  the  ulcerated  surfaces, 
followed  by  an  irrigation  with  warm,  normal  salt  solution  is 
often  beneficial.  In  some  cases  it  is  well  to  paint  the  whole 
surface  of  the  stricture  with  Lugol's  solution  of  iodine  (Liq. 
iodi.  comp.). 

A  very  satisfactory  sound  for  gradual  dilatation  of  a  stric- 
ture is  the  Kelly  dilator  for  the  female  urethra   an  illustration 


Fig.  103. — Kelly's  dilator  for  female  urethra. 

of  which  is  shown.  Care  should  be  exercised  not  to.  exert  much 
force  in  passing  any  sound  in  the  rectum,  as  it  is  very  easy  to 
perforate  or  tear  the  rectal  wall.  One  of  the  safest  instruments 
for  dilatation  is  a  soft  rubber  Wales  bougie. 

If,  in  spite  of' all  treatment  the  stricture  continues  to  contract, 
and  the  obstructive  and  ulcerative  symptoms  increase,  radical 
surgical  treatment  should  be  advised.  Rapid  dilatation  under 
anaesthesia  often  results  disastrously  from  tearing,  followed  by 


922  THE    GASTRO-IXTESTINAL    CLINIC 

serious  hemorrhage  or  secondary  infection.  Simple  division 
of  the  stricture,  or  internal  proctotomy,  is  apt  to  be  followed  by 
infection  due  to  insufficient  drainage.  Fairly  good  results  may 
be  obtained  by  performing  a  complete  posterior  linear  proc- 
totomy, dividing  the  stricture  and  carrying  the  incision  through 
the  internal  and  external  sphincters  and  well  back  to  the  tip 
of  the  coccyx  on  the  skin  surface.  Incontinence  rarely  results, 
and  the  danger  of  infection  is  very  slight.  After  all  of  these 
operations  the  dilatation  must  be  kept  up,  as  the  tendency  of 
the  cicatrices  to  contract  persists.  Excision  of  the  stricture  has 
so  often  been  followed  by  a  second  and  much  \vorse  contrac- 
tion, that  it  is  a  question  if  the  operation  is  really  indicated. 
Where  the  obstruction  is  so  great  as  to  endanger  the 
patient's  life,  permanent  coJostoni}'  should  be  immediately 
performed. 

In  conjunction-  with  the  local  treatment  the  patient's  gen- 
eral health  should  be  kept  up.  In  specific  cases,  the  iodides  are 
to  be  used  as  indicated,  but  they  appear  to  have  no  effect  on 
the  local  condition.  In  tubercular  cases,  tonics  and  intestinal 
antiseptics  are  indicated. 

Stricture  or  obstruction  caused  by  malignant  disease  will  be 
discussed  under  that  heading. 

ULCERATIONS   OF   THE   RECTUM 

Ulcerations  of  the  rectal  mucosa  are  of  frequent  occurrence, 
and  conform  in  many  instances  to  the  types  found  throughout 
the  intestinal  tract  above,  especially  to  those  forms  involving 
the  colon. 

Varieties  and  Etiology. — The  most  common  types  are  those 
due  to  acute  catarrhal  proctitis,  tuberculosis,  and  dysentery. 
The  ulcerations  which  are  confined  more  particularly  to  the 
rectum  are  the  venereal,  the  diphtheritic,  and  the  erosions  due 
to  stricture.  In  the  hemorrhoidal  area  quite  extensive  ulcera- 
tion may  be  produced  by  strangulation  or  thrombosis  of  in- 
ternal hemorrhoids,  or  from  the  application  or  injection  of 
caustic  solutions.  ^ 


DISEASES    OF    THE    RECTUM    AND    ANUS  923 

The  symptoms  of  rectal  ulceration  are  rather  indefinite,  usu- 
ally assuming  the  form  of  vague  uneasiness  in  the  rectum,  little 
or  no  pain,  accompanied  by  a  frequent  desire  to  go  to  stool,  es- 
pecially during  the  day  when  the  patient  is  on  his  feet.  If  the 
ulceration  is  situated  near  the  anal  margin,  there  is  usually 
considerable  pain,  with  marked  spasm  of  the  sphincter  often 
associated  with  constipation,  the  constipation  being  probably 
secondary  to  the  sphincterismus.  The  stools  are  often  mixed 
with  mucus,  pus,  and  blood.  \Mth  the  aid  of  the  proctoscope, 
the  ulcers  should  be  carefully  examined,  and  either  some  of  the 
discharge  or  a  scraping  from  the  floor  of  the  ulcer  should  be  ob- 
tained for  bacteriologic  examination. 

The  treatment,  in  conjunction  with  such  internal  medication 
as  may  be  indicated  by  the  systemic  condition,  should  include  a 
daily  irrigation  of  the  rectum  with  antiseptic  or  soothing  solu- 
tions. A  warm,  normal  salt  solution  will  often  be  found  bene- 
ficial, or  we  may  employ  a  solution  of  boric  acid,  gr,  5  to  oi- 
Where  there  is  much  tenesmus,  the  injection  of  olive  oil,  with 
or  without  bismuth  subnitrate,  or  an  injection  of  starch  water, 
will  be  found  ver}^  soothing.  The  local  application  of  nitrate  of 
silver  or  iodine  to  the  ulcers  will  often  stimulate  them  and  pro- 
duce a  cure.  AVhen  there  is  much  pain  and  sphincterismus  a 
divulsion  of  the' sphincters  will  relieve  the  distressing  symp- 
toms. The  introduction  of  a  suppository  containing  3  minims 
of  ichthyol,  used  three  or  four  times  a  day,  is  a  valuable  pro- 
cedure. 

BENIGN   TUMORS   OF   THE   RECTUM 

Benign  tumors  are  frequently  encountered  in  the  rectum,  and 
may  conform  to  any  of  the  histologic  forms  found  in  other 
portions  of  the  anatomy,  such  as  the  mucous,  lipomatous,  or 
fibroid  variety.  The  tumor  most  frequently  seen  is  the  polyp, 
or  pedunculated  growth,  which  may  be  made  up  of  any  of  the 
above  histologic  elements.  The  mucous  polyp  is  of  most  fre- 
quent occurrence,  and  may  be  found  either  in  children  or 
adults.    These  tumors  are  said  to  develop  from  an  enlarged  or 


924  THE    GASTRO-INTESTINAL   CLINIC 

hypertrophied  solitai-y  follicle  in  the  rectum,  which,  from  ir- 
ritation and  traction,  has  caused  an  elongation  of  the  mucous 
membrane,  thus  forming  a  distinct  pedicle.  They  usually  take 
their  origin  at  a  point  from  one  to  four  inches  above  the  anal 
margin,  although  they  may  be  found  located  in  the  sigmoid 
flexure  or  above. 

The  symptoms  of  polyp  of  the  rectum  are  usually  a  sense  of 
fullness  or  of  a  foreign  body  in  the  rectum,  a  frequent  desire 
to  go  to  stool,  attended  at  times  with  the  passage  of  consider- 
able mucus,  and  an  occasional  history  of  repeated  hemorrhage. 
If  the  pedicle  is  very  long,  or  the  growth  situated  low  down  in 
the  rectum,  the  tumor  may  protrude  at  stool.  In  these  cases 
there  is  apt  to  be  associated  spasm  of  the  sphincters  resulting 
in  considerable  pain. 

The  diagnosis  is  easily  verified  upon  digital  examination, 
when  a  movable  growth  attached  by  a  pedicle  can  be  readily 
made  out.  By  pressing  the  growth  firmly  against  the  rectal 
wall  under  the  index  finger,  it  may  frequently  be  delivered 
through  the  anus.  If  the  growth  is  situated  beyond  the  reach 
of  the  finger,  it  may  usually  be  seen  with  the  aid  of  a  procto- 
scope, especially  after  the  rectum  has  been  well  inflated  with 
air. 

The  treatment  of  this  variety  is  quite  simple,  and  when  the 
pedicle  is  small,  consists  in  seizing  it  with  two  hemostats, 
when  the  whole  growth  may  be  removed  by  slowly  twist- 
ing the  distal  hemostat  while  holding  the  other  firmly.  If  the 
pedicle  is  thick,  it  is  safer  to  ligate  first  either  by  a  simple  liga- 
ture, or  else  by  transfixing  the  pedicle  and  ligating  in  two 
halves.  If  general  anaesthesia  is  used,  the  pedicle  may  be 
seized  with  a  hemorrhoidal  clamp,  the  polyp  cut  ofT  close  to  the 
clamp,  and  the  stump  cauterized  with  a  Paquelin  cautery.  The 
rectum  should  be  irrigated  daily  for  about  a  week  with  a  mild 
antiseptic  solution,  when  the  stump  will  usually  be  found  to 
be  healed. 

When  multiple  adenomas  or  large  villous  tumors  are  found  in 
the  rectum,  because  of  their  proneness  to  be  followed  by  malig- 


DISEASES    OF    THE    RECTUM    AND   ANUS  925 

nant  degeneration,  nothing  short  of  the  most  radical  surgery 
should  be  thought  of,  and  the  case  should  be  at  once  placed  in 
the  hands  of  a  skilled  surgeon  for  operation.  For  the  differ- 
ential diagnosis  of  these  rarer  and  more  serious  forms  of 
tumor,  the  reader  must  be  referred  to  the  larger  text-books 
bearing  on  this  subject. 

It  is  a  good  plan,  after  the  removal  of  any  tumor  from  the 
rectum,  benign  or  otherwise,  to  have  the  patient  report  for  a 
rectal  examination  at  regular  intervals  of  from  three  to  six 
months.  Were  this  method  a  routine  one,  there  is  no  doubt 
but  that  the  percentage  of  inoperable  cases  of  malignant  dis- 
ease would  be  much  smaller. 

MALIGNANT  TUMORS 

The  great  increase  in  the  past  few  years  of  the  mortality 
from  malignant  disease  renders  the  diagnosis  of  this  condition, 
when  involving  the  rectum,  one  of  great  importance.  Again, 
the  uniformly  fatal  termination  of  these  cases,  except  when  a 
radical  operation  has  been  performed  early,  renders  the  neces- 
sity of  making  the  diagnosis  in  an  early  stage  of  the  disease 
imperative.  These  tumors  may  be  divided  into  two  great 
classes,  carcinoma  of  the  epithelial  type,  and  sarcoma,  or 
tumors  in  which  the  morphologic  constituents  conform  to  the 
connective-tissue  type. 

Varieties. — Of  the  first  class  of  neoplasms,  we  recognize  four 
varieties :  Epitheliomatous,  adenoid,  medullary,  and  scirrhous 
cancers. 

The  most  malignant  variety  is  the  medullary,  while  scirrhus 
may  persist  for  a  long  period,  months,  or  even  years,  before 
causing  death.  Epithelioma  is  most  frequently  found  on  the 
skin  surface  at  the  margin  of  the  anus,  while  scirrhus  is  usually 
located  in  the  sigmoid  or  upper  rectum.  The  remaining  two 
varieties  are  usually  met  with  in  the  rectum  proper. 

The  aetiology  of  carcinoma  is  yet  in  doubt.  Age  can  hardly 
be  claimed  as  a  markedly  predisposing  factor,  as  we  fre- 
quently come  in  contact  with  the  disease  in  very  early  adult 


926  THE    GASTRO-INTESTINAL    CLINIC 

life.  Heredity  may  be  a  factor,  but,  aside  from  accounting 
for  a  lowered  power  of  resistance  of  tlie  tissues  to  this 
(probably)  special  infection,  its  influence  seems  problematic. 
It  will  likely  be  found  that,  as  the  rectum  and  sigmoid  are  more 
often  the  seats  of  irritation,  ulceration,  inflammation,  and  trau- 
matism than  any  other  portions  of  the  intestinal  tract,  they  are 
more  often  involved  in  thi^  disease  process. 

The  symptoms  of  beginning  carcinoma  of  the  rectum  are 
vague  and  uncertain,  often  resembling  those  of  simple  ulcera- 
tion or  of  benign  stricture.  They  are  constipation,  a  vague 
sense  of  uneasiness  in  the  rectum,  pains  in  the  pelvis  and  thighs, 
flatulence,  followed  frequently  by  a  mucous  diarrhea,  often  out 
of  proportion  to  the  apparent  conditions,  and  usually  worse  in 
the  daytime.  Early  in  the  disease  there  may  be  no  apparent 
alteration  in  the  general  health.  As  the  disease  progresses  the 
symptoms  increase,  with  gradual  loss  of  weight  and  strength, 
increase  of  mucus  complicated  by  the  presence  of  pus  and  blood, 
and  a  gradual  increase  in  pain.  If  the  growth  is  low  down, 
near,  or  involving  the  anus,  the  pain  increases  rapidly.  A\^hen 
the  tumor  is  high  up,  as  in  scirrhus  of  the  sigmoid,  the  ob- 
structive symptoms  will  be  more  pronounced.  Only  too  often 
the  patient  has  lulled  himself  into  a  sense  of  false  security  by 
taking  it  for  granted  that  his  trouble  was  all  due  to  piles.  Too 
much  stress  cannot  be  laid  upon  the  fact  that,  when  a  patient 
complains  of  a  diarrhea  that  cannot  be  checked  by  medication 
in  a  few  days,  a  careful  digital  and  proctoscopic  examination  of 
the  rectum  should  be  made. 

The  diagnosis  of  carcinoma  in  the  lower  four  inches  of  the 
rectum  can  usually  be  made  by  digital  examination  alone.  The 
one  thing  that  impresses  the  examining  finger  the  most  is  the 
sense  of  resistance  or  infiltration.  The  finger  feels  as  if  it  had 
come  in  contact  with  a  stone  wall,  and  all  the  tissues  around 
feel  unyielding.  This  is  probably  due  to  the  fact  that  the  mu- 
cous membrane  is  not  movable  over  the  tumor  as  it  is  in  the 
early  stages  of  sarcoma.  The  growth  is  often  more  or  less 
lobulated.     In  epithelioma  of  the  anus   there  is  also  consider- 


DISEASES    OF    THE    RECTUM    AND    ANUS  92/ 

able  induration  attended  with  ulceration,  presenting  a  raised 
base  and  sharply  outlined  margins  and  a  tendency  to  scab  over. 
This  scab  breaks  down  repeatedly,  each  time  leaving  the  ulcer 
larger  than  before. 

\Mien  the  carcinoma  involves  the  upper  rectum  or  sigmoid, 
the  pneumatic  proctoscope  will  render  valuable  assistance  in 
making  the  diagnosis.  The  growth  in  most  cases  causes  a''stric- 
ture  in  the  caliber  of  the  gut,  but  the  surface  of  the  stricture  will 
be  found  intensely  inflamed  or  ulcerated,  while  in  benign  stric- 
ture of  the  rectum,  the  surface  of  the  stricture  will  be  found 
smooth  and  glistening,  the  ulcerations  being,  as  a  rule,  situated 
above  and  below  it. 

Enlargement  of  the  pelvic  or  inguinal  lymphatic  glands  may 
or  may  not  be  present,  while  in  some  cases  secondary  involve- 
ment of  the  liver  or  abdominal  viscera  may  be  found. 

The  growth  usually  surrounds  the  whole  rectum,  yet  at 
times  it  may  only  involve  a  small  area.  To  verify  the  diag- 
nosis, it  is  best,  if  possible,  to  remove  a  small  portion  of  the 
growth  for  microscopic  examination. 

Treatment — Once  the  diagnosis  has  been  established,  the 
question  of  treatment  is  a  very  serious  one.  The  case  should 
at  once  be  examined  by  a  competent  surgeon  to  decide  as  to 
the  advisability  of  a  radical  operation.  While  the  ultimate 
cures  from  operation  are  discouragingly  few,  yet  the  condition, 
if  left  alone,  is  so  absolutely  fatal  that  it  is  a  question  whether 
it  is  not  justifiable  to  tell  the  patient  his  exact  condition  and  al- 
low him  to  choose  the  few  chances  of  surviving  an  operation 
(one  to  four)  with  a  very  remote  hope  of  recovery,  or  to  wait 
for  the  inevitable  termination  of  the  disease  when  only  pallia- 
tive measures  are  employed.  Except  in  scirrhus  the  patient 
rarely  lives  over  a  year  or  a  year  and  a  half  without  operation, 
while,  even  if  the  growth  returns  after  operation,  he  has  been 
relieved  of  many  of  his  symptoms  and  has  had  his  life  prolonged 
probably  from  six  months  to  two  years  or  more. 

Where  the  growth  is  manifestly  inoperable,  or  where  the  pa- 
tient refuses  operation,  much  good  can  be  done  by  careful  at- 


928  THE    GASTRO-INTESTINAL   CLINIC 

tention  to  the  patient's  diet,  feeding  him  on  partially  digested 
and  unirritating  foods.  The  bowels  should  be  kept  freely  open 
either  by  castor  oil  or  the  use  of  non-irritating  enemas,  and 
the  rectum  should  be  freely  irrigated  daily  with  a  mild  anti- 
septic solution,  such  as  a  5  per  cent,  solution  of  boric  acid  or 
a  1-2  per  cent,  to  i  per  cent,  carbolic  solution.  If  bleeding  is 
persistent,  the  growth  m.ay  be  curetted. 

Since  the  x-ray  has  been  used  in  treating  malignant  tumors, 
we  may  hope  to  gain  some  benefit  from  its  employment,  but  it 
must  be  confessed  that,  so  far,  the  results  have  not  been  satis- 
factory, and  sufficient  time  has  not  elapsed  since  the  cures  re- 
ported to  prove  anything  as  to  their  permanency. 

MASSEY'S   IONIC   METHOD   BY   CATAPHORESIS  IN 
MALIGNANT   DISEASE 

The  treatment  of  malignant  disease  by  mnc-inercury  cata- 
phoresis  deserves  mention.  The  method  consists  in  the  inser- 
tion of  mercury-coated  zinc  electrodes  into  the  tumor  to  be 
destroyed.  When  the  electric  current  is  turned  on,  the  zinc 
and  mercury  undergo  electrolytic  changes,  uniting  with  the 
tissues  to  form  soluble  salts  of  these  metals.  As  the  result  of 
this  electro-chemic  action,  the  tumor  and  surrounding  tissues 
become  decolorized,  the  tumor  itself  softens  down,  and  ulti- 
mately comes  away  as  a  sterile,  odorless  slough.  The  sur- 
rounding tissues,  acted  upon  by  these  salts,  offer  a  zone  of  pro- 
tection against  metastasis  or  spread  of  infection.  Dr.  G.  Betton 
Massey  has  kindly  furnished  me  with  a  brief  outline  of  his 
technique  which  is  here  quoted : 

"  The  patient  is  anaesthetized  in  the  lithotomy  position, 
lying  upon  a  thick,  moist  pad,  under  which  is  the  negative  or 
indifferent  pole.  This  pad  should  cover  the  whole  dorsum  of 
the  patient.  The  sacral  region  should  be  protected  by  a  de- 
flated Kelly  pad  to  prevent  short-circuiting  of  the  current. 
Care  should  be  exercised  that  no  portion  of  the  indifferent 
plate  comes  in  direct  contact  with  the  patient,  or  a  severe  burn 
will  result.  After  etherization,  small  pointed  electrodes  of  zinc 
heavily  coated  with  mercury  are  inserted  directly  into  the 
tumor,  connected  with  the  positive  pole  of  a  constant  current 
apparatus  with  a  voltage  of  from  no  to  160  volts,  and  the 


I 


DISEASES    OF    THE    RECTUM    AND    ANUS 


929 


current  is  turned  on  until  about  200  milliamperes  for  each  point 
used  is  attained.     (See  illustration.) 

"  The  amperage  will  vary  with  the  size  and  position  of  the 
growth;  in  the  lower  rectum,  where  six  or  eight  points  have 


Fig.  104. — Short  electrodes  for  external  use. 

been  inserted  at  one  time,  1600  milliamperes  have  been  used. 
In  the  upper  rectum,  only  one  long  insulated  electrode  can  be 
employed,  allowing  the  use  of  from  250  to  350  milliamperes. 
(See  illustration.) 

"  When  the  current  is  connected  at  the  point  of  one  electrode, 
the  temperature  will  have  to  be  controlled  by  a  stream  of  cold 
water  used  at  intervals.     About  everv  half-hour  the  current 


Fig.  105. — Long  rectal  electrode  for  internal  use. 

must  be  turned  off,  and  a  freshly  amalgamated  electrode  in- 
serted. 

"  During  the  hour  and  a  half  to  two  hours  usually  required  to 
sterilize  and  destroy  a  large  growth,  repeated  examinations 
with  the  finger  and  miniature  lamp  will  show  a  progressive 
softening  of  the  growth  and  its  gradual  change  to  a  whitish- 
gray  color.     When  all  portions  are  softened  the  current  is 


930  THE    GASTRO-INTESTINAL    CLINIC 

turned  off,  the  electrodes  removed,  and  the  patient  put  to 
bed. 

"  The  after-treatment  is  purely  expectant.  Pain  rarely  lasts 
over  twenty-four  hours,  and  any  odor  present  disappears  en- 
tirely after  the  application,  the  slough  remaining  odorless  for 
some  days.  When  the  odor  returns,  and  the  sloughs  are  ready 
to  separate,  mild  antiseptic  douches  should  be  frequently  em- 
ployed. The  granulating  surface  remaining  should  be  kept 
clean,  and  mild  antiseptic  dressings  applied.  Should  the  slight- 
est sign  of  recurrence  appear,  repeat  the  treatment  imme- 
diately." 

Sarcoma  differs  from  carcinoma  of  the  rectum,  in  that  it  in- 
volves the  deeper  coats,  and  the  mucous  membrane,  early  in  its 
development,  is  movable  over  the  tumor.  While  the  growth  is 
dense  in  structure,  it  does  not  have  the  sense  of  hardness  to 
touch  noticed  in  carcinoma.  Because  the  mucous  membrane  is 
intact,  hemorrhage  is  absent  until  late  in  the  disease.  The 
growth  is  often  pedunculated,  and  is  more  apt  to  be  sharply  cir- 
cumscribed to  one  portion  of  the  rectal  wall.  The  disease  de- 
velops rapidly,  metastasis  takes  place  early,  and  a  fatal  termina- 
tion may  be  expected  in  from  six  months  to  a  year  and  a  half. 

The  only  possible  treatment  consists  in  early  and  complete 
excision  of  the  whole  growth.  The  application  of  caustics  or 
the  incopiplete  removal  of  the  growth  results  only  in  increasing 
the  malignancy  of  the  condition. 

During  the  six  years  since  the  first  edition  of  this  book  ap- 
peared, Dr.  Massey  has  been  making  a  large  use  of  his  ionic 
method  by  cataphoresis,  with  increasing  success.  In  the  Am. 
Jour,  of  Surg,  for  March,  1910,  he  summarized  a  part  of  his 
results  reporting  a  number  of  cases  which  have  remained  well 
5,  8,  9,  and  even  12  years  after  treatment.  These  results  seem 
striking  enough  to  attract  wide  attention  from  the  profession, 
especially  since  a  majority  of  the  cases  are  said  to  have  been 
found  previously  inoperable.  See  page  928  for  the  author's 
description  of  the  method. 


LECTURE  LXXX 

BACTERIA    AND    ANIMAL    PARASITES    IN 
THE  GASTRO-INTESTINAL  TRACT 

The  presence  of  bacteria  in  the  gastro-intestinal  tract  is  of 
double  significance.  Not  only  may  many  of  them  produce 
specific  lesions  and  cause  disease,  but  even  the  saprophytic 
bacteria  may  bring  about  changes  in  the  food  stuffs  resulting 
in  the  elaboration  of  highly  poisonous  ptomaines  which,  when 
absorbed,  give  rise  to  the  well-known  conditions  of  auto-intoxi- 
cation. Indeed,  many  of  the  symptoms  accompanying  gastro- 
intestinal derangements  are  due  to  the  effect  of  these  subtle 
poisans  on  the  nervous  system.  When  it  is  remembered  that 
the  gastro-intestinal  mucosa  is  really  an  internal  cutaneous 
surface,  and,  like  the  skin,  forms  a  barrier  to  the  entrance  of 
micro-organisms,  it  is  not  surprising  that  bacteria  may  thrive 
in  the  normal  gastro-intestinal  tract  without  producing  any 
serious  harm ;  but  let  there  arise  an  abnormal  condition  in  the 
mucous  membrane,  let  there  occur  a  locus  minoris  resistantice, 
and  bacteria  hitherto  harmless  invade  the  injured  mucosa 
and  produce  disease.  In  the  case  of  dilatation,  or  atony,  the 
stagnation  of  the  food  favors  the  multiplication  of  putre- 
factive bacteria  and  consequent  formation  of  poisonous  pto- 
maines. 

The  constant  presence  of  bacteria  in  the  normal  intestines 
has  led  some  authorities  to  the  conclusion  that  many  of  them 
are  concerned  in  the  process  of  digestion.  This  view,  how- 
ever, is  hardly  tenable.  Aside  from  the  fact  that  repeated  ex- 
periments on  animals  have  demonstrated  that  digestion  can  be 
carried  on  in  the  absence  of  micro-organisms,  the  proposition 
that  bacteria  are  necessary  adjuncts  in  the  process  of  digestion 
is  contrary  to  our  physiologic  conceptions.     One  might  as  well 

931 


932  THE    GASTRO-INTESTINAL   CLINIC 

argue  that  artificial  ferments  are  necessary  in  health  to  aid  di- 
gestion ;  yet  we  know  that,  under  normal  conditions,  the  gastro- 
intestinal ferments  digest  just  as  much  food  as  is  needful  for 
perfect  nutrition,  and  excess  of  digestion  would  tax  unduly 
the  absorptive  and  eliminative  organs,  and  lead  to  disturbed  as- 
similation. Besides,  under  normal  conditions,  the  motility  of 
the  stomach  and  small  intestines  does  not  give  the  bacteria 
time  enough  to  act  with  sufficient  force.  Whatever  changes  in 
the  undigested  food  the  intestinal  bacteria  may  and  do  pro- 
duce, such  as  the  formation  of  indol,  skatol,  and  various  gases, 
such  changes  are  secondary  and  unessential,  and  are  only  toler- 
ated by  the  organism  to  a  certain  limited  extent. 

The  bacteria  which  invade  the  gastro-intestinal  tract,  coming 
as  they  do  from  the  outside  world,  represent  the  various 
groups,  as  cocci,  bacilli,  spirilla,  sarcinse,  etc.  Many  of  them 
cannot  be  cultivated  on  any  of  our  artificial  media,  and  our 
knowledge  concerning  them  is  therefore  incomplete.  In  the 
mouth  Miller  isolated  about  30  species.  Of  these,  Leptothrix 
innominata.  Bacillus  buccalis  maximus,  Leptothrix  buccalis 
maxima,  lodococcus  vaginatus,  Spirillum  sputigenum,  and 
Spirochseta  dentium  are  normal  inhabitants,  though  all  are 
non-pathogenic.  Of  the  pathogenic  micro-organisms,  many 
occur  in  the  healthy  mouth  without  producing  disease.  Thus 
streptococci,  staphylococci,  pneumococci,  micrococcus  tetra- 
genes,  and  even  diphtheria  bacilli  may  be  present  in  the  mouths 
of  perfectly  healthy  individuals.  It  is  noteworthy  that  the 
pneumococcus  was  first  isolated  by  Pasteur  from  the  saliva  of 
a  boy  suffering  from  rabies,  and  by  Sternberg  from  his  own  sa- 
liva. The  presence  of  pathogenic  bacteria  in  the  mouths  of 
healthy  individuals  is  explained  by  the  assumption  that  such 
individuals  possess,  for  the  time  being,  a  natural  or  acquired 
immunity  from  the  particular  affections  the  specific  germs  of 
which  happen  to  gain  access. 

Other  micro-organisms  pathogenic  to  animals  have  been, 
from  time  to  time,  isolated  from  the  saliva,  and  while  not 
distinctly  pathogenic  to  man,   such  organisms  may  produce 


BACTERIA^    ETC.^    IN    THE    GASTRO-INTESTINAL   TRACT        933 

divers  affections  of  the  gums  and  teeth.  It  is  beheved  by  some 
investigators  that  the  saHva  exerts  an  antiseptic  action  on 
pathogenic  bacteria. 

In  the  stomach  only  a  few  bacteria  are  found  under  normal 
conditions,  this,  no  doubt,  being  due  to  the  antiseptic  action  of 
the  gastric  juice,  aided  by  the  frequent  emptying  of  that 
viscus.  However,  certain  yeasts  and  yellow  sarcinas  are  found, 
and  many  bacteria,  especially  those  producing  acid  fermenta- 
tion, will  thrive  in  the  stomach,  even  in  the  presence  of  ex- 
cessive amounts  of  HCl.  Pathogenic  bacteria  are  more  sus- 
ceptible to  the  action  of  HCl,  but  even  they  will  escape  unin- 
jured, being  protected  by  the  bolus  of  food.  Under  abnormal 
conditions,  such  as  deficiency  of  HCl  or  stenosis,  with  de- 
creased motility  and  in  dilatation,  numerous  bacteria  may  be 
found  in  the  stomach.  Many  of  them  cause  fermentation  and 
putrefaction,  and  it  is  to  these  changes  in  the  gastric  contents 
that  many  of  the  symptoms  accompanying  these  affections  are 
due.  The  Oppler-Boas  bacillus,  an  unusually  long,  non-motile 
micro-organism,  is  claimed  by  its  discoverers  to  be  constantly 
present  in  gastric  cancer.  Its  presence,  however,  is  not  path- 
ognomonic of  that  affection. 

In  the  intestinal  tract,  B.  coli  communis,  B.  lactis  erogenes, 
B.  putrificus  coli,  and  Streptococcus  coli  gracilis  are  perma- 
nent inhabitants.  B.  erogenes  capsulatus,  B.  butyricus,  and 
numerous  other  micro-organisms  may  be  temporarily  present. 
It  is  to  be  remembered,  however,  that  the  bile,  to  some  extent, 
and  in  all  probability  the  intestinal  secretions,  exert  an  anti- 
septic action  on  bacteria,  and  many  micro-organisms  found  in 
the  feces  are  dead.  This,  in  part,  accounts  for  the  failure  to 
cultivate  some  of  the  bacteria  which  are  observed  in  the  feces 
on  direct  microscopic  examination.  Of  the  pathogenic  va- 
rieties, B.  typhosus  is  present  early  in  typhoid  fever ;  B.  tuber- 
culosis, in  intestinal  tuberculosis ;  B.  anthracis,  in  intestinal  an- 
thrax; B.  dysentericus,  in  dysentery;  Spirillum  cholerse  asi- 
aticse,  in  cholera;  Spirillum  Finkler-Priori  possibly,  in  cholera 
nostras,  and  B.  botulinus,  in  meat  poisoning.    The  importance 


934  THE    GASTRO-INTESTINAL   CLINIC 

of  carefully  disinfecting  the  stools  in  all  these  affections  be- 
comes self-evident. 

The  bacteria  of  the  gastro-intestinal  tract  are  derived  from 
the  air  and  food.  Those  from  the  air  are  lodged  in  the  mouth 
and  find  their  way  into  the  stomach  and  intestines  with  the 
saliva  and  the  food.  While  in  this  way  pathogenic  bacteria 
may  gain  entrance  and  set  up  specific  lesions  in  the  stomach  or 
intestines,  the  much  more  serious  danger  lies  in  the  ingestion 
of  pathogenic  bacteria  contained  in  food.  It  is  a  matter  of 
common  experience  that  typhoid  and  tubercle  bacilli  may  be 
transmitted  through  milk,  and  the  latter  micro-organism  may 
be  also  contained  in  the  meat  from  tuberculous  animals.  Milk, 
on  account  of  its  being  a  most  suitable  culture  medium,  is  es- 
pecially prone  to  contain  fermentative  as  well  as  pathogenic 
bacteria.  Investigations  carried  on  in  New  York,  Philadel- 
phia, and  other  cities  disclosed  a  most  deplorable  condition  of 
the  milk  supply  of  large  cities.  Aside  from  pathogenic  bac- 
teria, which  such  milk  may  and  in  many  cases  does  contain, 
the  micro-organisms  commonly  found  in  polluted  milk  are 
capable  of  producing  synthetic  changes  in  the  milk,  rendering 
it  injurious  to  babies  and  invalids.  The  pity  of  it  is  that  pas- 
teurization does  not  destroy  spores,  and  boiling  changes  the 
character  of  the  milk  to  such  an  extent  as  to- render  it  some- 
what less  digestible. 

Meat  may  contain  putrefactive  bacteria,  tubercle  bacilli,  or 
the  ova  of  animal  parasites. 

Uncooked  fruit  and  vegetables  may  be  the  carriers  of  patho- 
genic and  putrefactive  bacteria,  and  it  is  frequently  in  this  way 
that  disease  is  contracted. 

Fish,  especially  shell  fish,  may  carry' the  typhoid  bacillus  or 
putrefactive  bacteria  derived  from  sewage-polluted  beds. 

Water,  when  polluted  with  sewage,  may  contain  the  typhoid 
bacillus,  the  cholera  spirilKuPi  (in  times  of  an  epidemic  of 
cholera),  the  bacillus  of  dysentery,  and  other  micro-organisms 
still  unidentified,  which  produce  digestive  disturbances  and 
diarrheal  diseases. 

It  is  thus  seen  that  the  harmful  bacteria  found  in  the  gastro- 


BACTERIA,    ETC.,    IN    THE   GASTRO-INTESTINAL   TRACT         935 

intestinal  tract  are  derived  from  food  and  drink,  and  it  be- 
hooves us  to  guard  most  zealously  against  contamination  of 
the  food  taken  by  the  well,  and  more  especially  by  the  sick  and 
feeble. 

As  a  corollary  to  the  subject  under  consideration,  the  ques- 
tion of  intestinal  antiseptics  may  be  taken  up.  The  antiseptics 
provided  by  nature  are  the  HCl  of  the  gastric  juice,  possibly 
the  bile,  and  probably  other  secretions,  the  existence  of  which 
we  can  only  suppose  a  priori.  However,  as  already  mentioned,, 
even  these  natural  antiseptics  have  their  limitations,  for  the 
hardier  micro-organisms  are  not  affected  by  them.  In  the  case 
of  the  gastric  juice,  it  is  only  the  free  and  not  the  combined 
HCl  which  exerts  any  antiseptic  action  at  all.  Moreover, 
natural  antiseptics  are  biologic  in  nature,  and  act 
in  minute  quantities.  How  different  is  the  case  with  arti- 
ficial chemical  antiseptics.  In  the  first  place,  they  are  all  un- 
stable organic  compounds,  and  they  may  undergo  such  changes 
.  in  the  gastro-intestinal  tract  as  to  have  completely  altered  their 
properties.  In  the  second  place,  they  are  diluted  by  the  food 
and  gastro-intestinal  secretions  to  such  an  extent  as  to  render 
them  practically  inert,  and  if  employed  in  sufficient  concentra- 
tion, act  injuriously,  not  only  on  the  bacteria,  but  also  on  the  se- 
creting cells.  It  therefore  appears  irrational  to  depend  much 
on  intestinal  antiseptics,  the  ever-increasing  number  of  which 
in  itself  proves  their  comparative  worthlessness.  It  would 
seem  far  more  rational  to  prevent  the  entrance  of  harmful 
bacteria  into  the  gastro-intestinal  tract,  than  to  permit  them  to 
enter  into  the  deep  recesses  of  our  internal  anatomy,  and  then 
hunt  them  down  with  yard-long  synthetic  formulae. 

The  animal  parasites  which  are  found  in  the  gastro-intestinal 
tract,  and  which  may  be  productive  of  diseases  of  these  organs, 
are  protozoa  and  vermes.  Of  the  former,  the  Amoeba  coli,  a 
unicellular  animal  organism,  is  concerned  in  the  production  of 
tropical  dysentery  and  hepatic  abscesses.  However,  later  in- 
vestigations by  Shiga  (of  Japan),  Kruse  (of  Germany),  Flex- 
ner  and  his  pupils,  Vedder  and  Duval,  in  this  country,  have 


936  THE    GASTRO-INTESTINAL    CLINIC 

shown  that  certain  cases  of  sporadic  and  epidemic  dysentery 
are  caused  by  a  specific  bacillus,  first  isolated  and  described  by 
Shiga.  Another  protozoan  belonging  to  the  Ciliata,  Balan- 
tidium  coli,  causes  severe  diarrhea.  In  all  nine  different 
bacilli  have  been  recognized  as  causes  of  the  numerous  cases 
of"' dysentery  observed  among  the  returning  pilgrims  at  Tor, 
Egypt. 

The  vermes,  Cestoda  and  Nematoda,  are  commonly  found  in 
the  intestinal  tract.  They  cause  pathologic  changes,  either  me- 
chanically, by  occluding  cavities,  producing  obstruction,  or 
chemically,  by  generating  irritating  poisons.  In  the  case  of  the 
tapeworm,  the  large  size  of  the  parasite,  which  obtains  its 
food  by  absorption,  may  interfere  with  nutrition;  the  tape- 
worm, Bothriocephalus  latus,  producing  in  addition  a  systemic 
poison.  The  round  worms  are  extremely  irritating,  and  diar- 
rhea, vomiting,  and  other  gastro-intestinal  disturbances  are 
the  result  of  their  irritating  action.  The  seat- worm,  on 
account  of  its  very  irritating  properties  and  migratory 
habits,  is  liable  to  lead  to  masturbation,  either  by  direct  irrita- 
tion of  the  genitals,  or  by  indirect  reflex  irritation  of  the  anus. 
Recently,  Metchnikoff  advanced  the  theory  that  the  Nematoda, 
or  round  worms,  are  frequently  the  cause  of  appendicitis,  which 
they  are  said  to  produce  by  irritating  the  appendix  and  favor- 
ing bacterial  infection.  This  theory  seems  to  be  supported  by 
his  own  observations,  as  well  as  the  experience  of  some  other 
observers,  although  the  subject  has  been  investigated  by  a 
number  of  men  who  failed  to  substantiate  it.  The  vermes, 
which  may  be  found  in  the  intestinal  tract,  are  Ascaris  lumbri- 
coides,  Oxyuris  vermicularis,  Trichocephalus  dispar,  Anky- 
lostoma  duodenale.  Tenia  solium,  Tenia  saginata,  and  Both- 
riocephalus latus.  They  are  considered  more  in  detail  in  the 
following  section. 

THE    INTESTINAL    PARASITES 

These  are  described  with  sufficient  fullness  in  most  of  the 
text-books  on  Practice,  but  a  brief  account  of  them  will  be  in 
place  here.     The  diagnosis  of  worms  should  rest  on  one  thing 


BACTERIA,    ETC.,    IN    THE    GASTRO-INTESTINAL   TRACT        gT,^ 

only,  and  that  is  the  finding  of  either  the  worms  or  their  eggs 
in  the  feces.  Intestinal  parasites  act  primarily  as  irritants,  and 
the  symptoms  of  reflex  irritation  do  not,  as  a  rule,  differ  from 
those  produced  by  any  other  irritant.  Moreover,  the  symp- 
toms are  extremely  variable,  and  lack  altogether  in  uniformity 
or  constancy,  except  in  the  case  of  ankylostoma  duodenale. 
Between 'pruritus  ani,  or  the  irritation  due  to  pinworms,  and 
severe  digestive  disturbances  caused  by  tapeworms,  there  is  a 
variety  of  conditions  produced  by  the  various  parasites,  con- 
ditions in  no  way  differing  from  those  due  to  other  factors. 
To  make  a  diagnosis  of  worms  without  a  careful  examination 
of  the  feces,  is  to  do  the  patient  harm  by  mistaking  the  true 
setiologic  factor  involved. 

In  cases  of  persistent  symptoms  referable  either  to  the  nerv- 
ous or  digestive  system,  especially  in  children,  you  should  think 
of  worms  and  look  for  them.  In  all  such  suspicious  cases,  in- 
struct the  patient  to  evacuate  his  or  her  bowels  in  a  vessel 
partly  filled  with  tepid  water,  and  then  carefully  examine  each 
evacuation  for  anything  which  looks  like  worms.  As  a  rule, 
any  layman  will  detect  readily  a  roundworm  or  a  tapeworm, 
though  mucus  is  sometimes  mistaken  for  them,  nor  does  the 
detection  of  oxyuris  or  pinworms  present  much  difficulty.  The 
suspected  worm,  if  found,  should  be  placed  in  a  bottle  contain- 
ing alcohol  or  formalin  for  further  examination. 

The  Principal  Varieties  of  Tapeworms,  etc. — The  identifi- 
cation of  the  adult  parasite  presents  little  difficulty.  Of 
the  more  common  ones,  the  tapeworm,  the  round  worm, 
and  the  threadworm,  are  of  interest  in  this  country.  Of 
the  tapeworm  (cestodes)  the  Tenia  solium  and  Tenia  medio- 
canellata  or  saginata  are  the  most  prevalent  varieties,  while  the 
Tenia  echinococcus  is  comparatively  rare,  and  the  bothriocepha- 
lus  latus  is  only  found  in  European  immigrants,  especially  those 
coming  from  Switzerland,  Germany,  and  the  Baltic  countries. 

The  T.  solium  develops  in  the  lower  part  of  the  small  intes- 
tines, the  infection  being  derived  from  insufficiently  cooked 
measly  pork,  where  the  parasite  exists  in  the  form  of  encysted 


938  THE    GASTRO-INTESTINAL   CLINIC 

larvae  called  cysticerci.  The  adult  worm  is  distinguished  by  the 
proglottides  or  segments  being  8  to  lo  mm.  long,  and  6  to  7 
mm.  broad,  and  the  branchings  of  the  uterus,  which  are  from 
seven  to  ten  in  number  and  divide  peripherally.  (See  Fig.  106, 
T.  S.) 

The  T.  saginata  is  distinguished  by  being  larger  than  the 
preceding.  The  segments  measure  18  mm.  by  7  to  9  mm.,  their 
number  being  about  1200  to  1600,  The  uterus  possesses  from 
20  to  30  branches,  which  divide  dichotomously  (Fig.  106,  T. 
Sg.).  The  segments  are  frequently  evacuated  spontaneously, 
apart  from  defecation. 

The  bothriocephalus  latus  is  the  largest  tapeworm  in  man. 
It  results  from  eating  infected  fish,  as  a  rule.  Its  segments,  of 
which  there  are  from  2400  to  3500,  measure  3  to  5  mm.  in 
length  and  12  mm.  in  breadth.  The  uterus  forms  a  rosette  in 
the  middle  of  the  segment.  (Fig.  106,  B.  L-)  In  order  to 
distinguish  the  uterus,  the  segments  may  be  pressed  between 
two  slides  and  held  up  to  the  light,  or  they  may  be  placed 
in  oil  of  cloves  until  translucent,  and  mounted  permanently  in 
balsam. 

It  is  often  important  to  know  whether  the  head  of  the  para- 
site has  been  removed.  The  heads  of  the  parasites  above  men- 
tioned are  distinguished  by  the  following  characteristics : 

T.  Solium. — The  head  is  about  imm.  in  diameter  and  fur- 
nished with  a  rostellum  and  26  booklets,  behind  which  are  4 
sucking  discs.     (Fig.  106,  H.  T.  S.) 

T.  Saginata. — The  head  is  1.5  to  2.5  mm.  in  diameter;  has 
neither  rostellum  nor  hooks,  and  possesses  4  large  discs  or 
suckers  which  are  surrounded  by  a  line  of  pigment.  Seg- 
mentation of  the  neck  cjuite  evident.    (See  Fig.  106,  H.  T.  Sg.) 

Bothriocephalus  latus. — The  head  is  very  small  and  flat, 
looking  like  an  enlargement  of  the  thin  neck.  It  is  marked  by 
two  deep  furrows  or  suckers  arranged  longitudinally.  (See 
Fig.  106,  H.  B.  L.) 

Of  the  nematodes,  the  ascaris  lumbricoides  and  oxyuris  ver- 
micularis  (threadworm)  are  the  most  common. 


BACTERIA,    ETC.,    IN    THE    GASTRO-INTESTINAL   TRACT        939 


//.  7!5p. 


H.B.L, 


BL 


% 

i 


Fig.    106.  — The    more    common    intestinal    parasites. 

H.T.Sg.,    Head    of   T.    Saginata;    T.Sg.,  Segments 

and,  i.sg.,  egg  of  T.  Saginata;  H.T.S.,  Head,  T.S., 

A    I  Segments,  and,  /.J.,  eggs  of  T.  Solium;    B.L.,  Seg- 

'*■  ^'  ments,  H.B.L.,  Head,  and,  b.l.,  egg  of  Bothrioceph- 

alus  latus;  O.  V.  and  'o.v.,  Oxyuris  vermicularis  (male  and  female)  and 

eggs;  A.L.  and  aj.,  Ascaris  lumbricoides  (male  and  female)  and  egg; 

yi./).,  Various  forms  of  Amoeba  dysenteriae. 


940  THE    GASTRO-INTESTINAL    CLINIC 

Ascaris  lumhricoidcs  is  represented  by  both  sexes.  The  male 
is  about  250  mm.  and  the  female  about  400  mm.  long.  The 
cylindric  body  tapers  toward  each  end,  presenting  four  longi- 
tudinal and  many  cross  stripes.  It  is  pale  red,  the  head 
being  slightly  different  in  color.  The  intestinal  canal  runs 
through  the  entire  worm.  The  female  possesses  a  thread- 
like twisted  double  uterus  which  may  contain  rnany  millions 
of  eggs. 

Oxyuris  verinicularis  is  a  small,  white,  thread-like  w^orm. 
The  male  is  about  3-4  mm.  and  the  female  8-12  mm.  long,  the 
tail  of  the  former  being  rolled  up,  while  that  of  the  latter  is 
tapering.  The  mouth  end  is  provided  with  three  lips,  and  the 
intestinal  canal  is  straight  and  in  the  mid-line. 

It  frequently  happens  that  the  adult  worms  are  not  found  in 
a  particular  specimen  of  feces,  and  the  urgency  of  the  case  de- 
mands an  immediate  examination,  or  it  may  be  that  the  adult 
forms  are  not  sufficiently  numerous  to  be  excreted  with  the 
feces  in  numbers  which  may  be  readily  detected.  Under  these 
circumstances,  an  effort  should  be  made  to  detect  the  eggs  in 
the  feces  by  a  careful  microscopic  examination. 

Diagnosis  of  the  Ova. — The  following  differential  points 
will  aid  in  distinguishing  the  eggs  of  the  various  para- 
sites: 

T .  Solium. — Eggs  ovoid,  about  35  microns  long.  They  de- 
velop into  the  cysticerci  cellulosi,  which  are  often  found  in 
man.  By  tearing  open  the  cyst  the  scolex  or  larvae  may  be  ob- 
served on  the  inner  wall.     (Fig.  106,  t.  s.) 

T.  Sagiiiata. — Eggs  more  oval  than  T.  solium ;  possess  a 
thick  shell  and  lining  membrane.  They  develop  into  cysticerci 
which  do  not  occur  in  man.     (Fig.  106,  t.  sg.) 

Bothriocephahis  latus. — Eggs  oval,  0.07  mm.  long  and 
0.045  ^^^^-  thick.  Surrounded  by  a  thin  brown  shell,  the  upper 
pole  of  which  is  marked  in  the  form  of  a  lid.  In  fresh  water 
they  develop  into  a  ciliated,  freely  moving  spherical  embryo. 
(Fig.  106,  b.  1.) 

Oxyuris  verinicularis. — Eggs  oval,  0.05  mm.  long,  contain- 


BACTERIA^    ETC.^    IN    THE    GASTRO-INTESTINAL   TRACT         94 1 

ing  an  embryo  with  a  sharp  posterior  end.  The  shell  is  flat- 
tened on  one  side,  and  surrounded  by  an  albuminous  substance. 
(Fig.  106,  o.  V.) 

Ascaris  lunibricoidcs. — Eggs  oval,  about  twice  as  large  as 
t-he  preceding;  possess  a  thick  double  shell,  surrounded  by  a 
layer  of  an  albuminous  substance.     (Fig.  io6,  a.  1.) 

The  treatment  required  for  the  expulsion  of  the  various 
kinds  of  intestinal  parasites  will  be  described  at  the  end  of  the 
entire  section  devoted  to  such  parasites. 

Amoeba  Dysenteriae — While  dysentery  occurring  in  this 
country  is  usually  due  to  some  one  of  various  bacilli,  includ- 
ing that  isolated  and  described  by  Shiga,  yet  there  are  also  cases 
of  that  affection  caused  by  an  amoeba.  This  protozoon  may  be 
found  in  large  numbers  in  the  lesions  as  well  as  the  feces.  The 
latter  are  best  examined  when  fresh,  or  at  least  not  over 
twenty- four  hours  old. 

The  Amoeba  dysenteriae,  or  more  commonly  called  Amoeba 
coli,  is  a  round,  oval,  or  irregular  protoplasmic  body,  varying 
in  size  from  lo  to  50  microns.  It  is  pale  or  faint  green  in  color, 
refractile,  with  sharply  outlined  borders,  and  contains  a  large 


r 


Fig.  107. — Amoeba  coli  mitis  or  vulgaris.     (After  Rocs.) 

vacuole,  and  in  some  cases  a  nucleus.  The  greater  central 
portion  of  the  parasite  contains  the  vacuoles,  and  is  known  as 
the  endoplasm ;  this  is  surrounded  by  a  narrow,  clear  layer, 
known  as  ectoplasm.  The  parasite  is,  as  a  rule,  actively  motile, 
throwing  out  psaudopodia.  It  frequently  contains  within  its 
endoplasm  foreign  substances,  such  as  various  granules  and 


942  THE    GASTRO-INTESTINAL    CLINIC 

fresh  or  disintegrated  red  blood  cells.  The  smear  may  be 
stained  with  alkaline  meth3-lene  blue  for  about  five  minutes 
and  then  washed  in  distilled  water. 

Amoeba  dysenteries  is  distinguished  with  difficulty  from 
Amoeba  coli  vulgaris,  which  is  a  harmless  inhabitant  of  the 
human  intestines.  It  is,  therefore,  well  in  all  cases  to  cor- 
roborate the  diagnosis  by  feeding  young  cats  on  the  feces  con- 
taining the  amcjebas.  If  the  amoebae  are  of  the  pathogenic 
variety,  dysentery  will  result  in  the  experimental  animals. 

Amoebic  dysentery,  the  disease  produced  by  this  organism,  is 
described  in  Lecture  LXXII. 

Ankylostotna  Duodenale,  or  Uncinaria  Duod This  para- 
site has  been  comparatively  unknown  in  the  'United  States  until 
very  recently.  It  has  been  long  familiar  to  physicians  on  the 
continent  of  Europe,  and  has  passed  in  some  quarters  under 
the  name  of  Egyptian  chlorosis.  It  is  endemic  in  Egypt  and 
the  southern  parts  of  Europe,  and  prevails  chiefly  among  the 
men  employed  in  brick  yards  or  tile  works,  but  also,  to  some 
extent,  among  farmers  who  work  much  in  moist  earth. 

The  parasite  has,  in  recent  years,  been  seen  in  this  country 
among  Italians  and  othgr  immigrants  from  the  South  of 
Europe,  but  a  form  of  it,  which  is  a  little  smaller,  and  differs  in 
other  respects  to  some*  degree  from  the  foreign  type,  is  now 
encountered  frequently  among  the  negroes  and  other  laborers, 
as  well  as  the  barefooted  children  in  our  Southern  States,  and 
has  been  named  by  Stiles  (1902)  Uncinaria  americana,  ac- 
cording to  Henry  B.  Ward,  who  contributes  the  article  on 
Nematoda  to  the  new  edition  of  Wood's  "  Reference  Hand- 
book," vol.  vi.,  page  205.^ 

Drs.  Herman  B.  Allyn  and  M.  Behrend  contributed  to 
American-  Medicine  of  July  13,  1901,  a  paper  on  Ankylosto- 
miasis in  the  United  States,  with  report  of  a  case  treated  by 
them  in  the  Philadelphia  Hospital.  Their  paper  contains  an  ex- 
cellent illustration  of  both  the  male  and  female  parasite,  which, 
by  their  courtesy  and  that  of  the  editor  of  American  Medicine, 
iSee  also  Stiles'  Bulletin,  Bureau  Pub.  Health  and  Marine  Hosp. 
Service. 


Fig.  108. — Ankylostoma  duodenale.  The  larger  one  at  th^  left  is  the  fe- 
male; A,  Head,  showing  teeth- and  glands;  B,  Esophagus;  C,  Mouth 
glands;  D,  Intestines;  E,  Genital  opening;  F,  Uterus  and  oviducts; 
G,  Anal  orifice. 

The  figure  on  the  right  is  the  male.  The  teeth  and  glands  show  more 
distinctly.  S,  Spermatic  ducts  containing  cells;  Z,  The  bursa  copula- 
trix.  (From  a  paper  by  Herman  B.  Allyn  and  M.  Behrend  in  Am.  Mea, 
of  Jnly  13,  1901,     By  permission.) 


944 


THE    GASTRO-INTESTINAL   CLINIC 


I  am  permitted  to  reproduce  here.  (See  illustration,  Fig. 
io8.) 

I  have  had  made,  also,  an  accurate  representation  of  the  ova 
of  Uncinaria  americana,  which  it  is  even  more  important  that 
you  should  be  able  to  recognize,  since  they  may  be  discovered 
under  the  microscope,  even  when  the  parasites  themselves  can- 
not be  found.     (See  illustration.  Fig.  109.) 

Ward  thus  describes  the  well-known  Uncinaria  duod.,  or  as 
formerly  called  most  frequently,  Ankylostoma  duod. : 

"  Body  cylindric ;  buccal  cavity,  with  two  pairs  of  uncinate 
ventral  teeth,  and  one  pair  of  dorsal  teeth,  directed  forward; 


Fig.   109. — Eggs  of    Uncinaria  americana  from  feces,      x.  330. 
(After  Stiles.) 

dorsal  rib  not  projecting  into  capsule.  Female,  10-18  mm. 
long,  by  0.5-0.6  mm.  wide;  vulva  at  or  near  posterior  third  of 
body ;  eggs  52  by  32  /^.  segmenting  when  deposited  with  direct 
development.  Male,  8- 11  mm.  long,  by  0.4-0.5  mm.  wide; 
caudal  bursa,  with  dorso-medial  lobe,  dividing  at  two-thirds 
the  distance  from  base,  each  branch  being  tridigitate,  and  with 
prominent  lateral  lobes  united  by  a  ventral  lobe ;  spicules  long, 
slender." 

This  form  of  parasite  is  found  in  many  parts  of  Europe, 
Asia,  and  Africa,  as  well  as  in  the  West  Indies,  and  not  in- 
frequently of  late  in  the  United  States. 


BACTERIA^    ETC.^    IN    THE    GASTRO-INTESTINAL  TRACT        945 

The  Uncinaria  americana,  described  by  Stiles  and  quoted 
by  Ward,  presents  the  following  characteristics : 

Ventral  recurved  uncinate  teeth  absent  from  mouth,  one 
pair  prominent  dorsal  semilunar  plates,  and  an  inconspicuous 
ventral  pair  being  present ;  dorsal  median  conical  tooth,  pro- 
jecting prominently  into  buccal  capsule.  Female,  9-1 1  mm. 
long,  by  0.31-0.35  mm.  wide;  vulva  near  middle  of  body,  but 
in  front  of  it;  eggs  (Fig.  109)  64-72  /<,  by  36-40  /O  seg- 
menting, or  with  well-developed  embryos  when  deposited. 
'Male,  7-9  mm.  long  by  0.29-0.31  mm.  wide;  dorsal  ray  of 
caudal  bursa  divided  to  the  base,  each  branch  bipartite  to  tip. 
Species  otherwise  similar  to  U.  duodenalis. 

Symptoms  of  Ankylosfoma,  etc. — The  chief  S}TTiptoms  are 
anaemia  and  debility,  which  are  often  very  marked  and  are 
caused  by  the  blood-sucking  habit  of  the  parasite ;  also  certain 
ofastro-intestinal  disturbances.  The  red-blood  cells  ha^-e  some- 
times  fallen  below  1,000,000.  These  include  especially  nausea 
with  often  vomiting,  flatulence,  constipation,  or  diarrhea,  se- 
vere gastric  or  colicky  pain,  and  marked  changes  in  appetite. 
There  -are  likely  to  be  also  dyspnoea,  vertigo,  dropsy  of  the 
lower  limbs,  cold  hands  and  feet,  and  occasionally  hemorrhages. 
Afternoon  fever  may  sometimes  be  observed,  and  extreme 
drowsiness  may  develop.  There  is  occasionally  leucocytosis, 
and  almost  invariably  marked  eosinophilia. 

Pathologically  the  disease  causes  the  changes  to  be  expected 
from  a  long  and  severe  anaemia,  with  much  congestion  and 
evidences  of  hemorrhage  in  the  intestinal  mucosa.  The  heart 
is  often  enlarged. 

The  diagnosis  turns  upon  the  observance  of  the  above- 
described  symptoms  in  connection  with  the  presence  of  either 
the  parasite  or  its  characteristic  ova  in  the  evacuations. 

The  prognosis  of  ankylostoma  duod.  is  good  if  appropriate 
treatment  is  begun  early,  and  in  persons  not  infested  with  too 
great  a  number  of  the  parasites.  Otherwise,  it  runs  a  pro- 
longed and  serious  course  and  often  terminates  fatally. 

Treatment  of  Ankylostoma  duod. — Any  of  the  remedies  for 
tapeworm  may  be  hopefully  employed,  but  the  greatest  success 


94^  THE    GASTRO-IXTESTINAL    CLINIC 

has  been  achieved  with  thymol,  and  with  the  male  fern.  Allyn 
and  Behrend  report  favorably  of  thymol,  lo  to  30  grns.  in 
water  at  8  a.  m.  (fasting-)  and  repeated  at  10  a.  m.^  followed 
in  two  hours  by  castor  oil,  or  Epsom  salt. 

Treatment  of  Tenia,  Round  and  Seat  Worms. — In  the  treat- 
ment of  tapczi'onn,  regardless  of  the  variety,  the  most  success- 
ful method  has  been  found  to  be  the  following : 

First,  to  empty  the  alimentary  canal  by  purgatives,  then 
limit  the  diet  strictly  to  a  few  very  simple  articles  for  one  day. 
The  Germans  insist  that  it  is  well  to  select  for  this  special  pre- 
liminary diet  articles  of  food  which  are  believed  to  act  in- 
juriously upon  the  worm.  These  include  onions  and  garlic, 
with  salt  herring,  all  chopped  finely  and  mixed  into  a  form  of 
salad.  Striimpell  attributes  to  strawberries,  cranberries,  and 
bilberries  a  similar  disturbing  action  upon  the  parasite.  After 
the  preliminary  evacuations  of  the  bowels  and  such  a  diet  as 
above  mentioned  for  one  day,  some  writers  advise  evacuating 
the  bowels  again  at  bedtime,  and  then  the  next  morning  to 
take  no  food  whatever,  unless  it  be  a  cup  of  black  coffee,  which, 
however,  may  be  sweetened, — though  the  maximum  doses  of 
male  fern  are  safer  after  a  meal.  Then,  it  is  in  order  to  admin- 
ister the  special  teniafuge  or  teniacide.  There  are  a  number  of 
such  remedies  which  have  been  employed  with  success.  These 
include  the  ethereal  extract  or  oleof esin  of  male  fern,  which  you 
may  give  in  doses  of  f  3  ss.  to  f  3  ii,  though  the  Germans 
carry  the  dosage  as  high  as  f  3  iiss.,  especially  for  tenia  solium; 
koosso,  in  the  form  usually  of  an  infusion,  one-half  ounce  of  the 
dried  flowers  in  a  pint  of  water ;  tannate  of  pelletierine  in  doses 
of  5  to  10  grains,  usually  effective,  but  very  expensive;  infusion 
of  pomegranate,  2  to  3  ounces  of  the  bark  in  a  pint  of  water; 
and  last,  but  by  no  means  least,  a  mixture  of  pumpkin  seeds 
chopped  up  finely  with  sugar.  Of  the  last-mentioned  mixture 
as  much  as  a  teacupful  may  be  given  to  adults,  and  in  propor- 
tion to  children.  It  is  a  safe  and  not  very  unpleasant  remedy 
to  take,  and  often  efficient.  Another  remedy  recently  recom- 
mended, concerning  which  I  have  had  no  experience,  is  the  oil 


BACTERIA_,    ETC.^    IN    THE    GASTRO-INTESTINAL   TRACT        947 

of  pine  needles,  given  in  half-dram  doses,  either  in  a  capsule 
or  in  emulsion.  These  remedies  usually  either  kill  or  benumb 
the  worm  so  that  a  brisk  cathartic,  given  two  to  three  hours 
later,  effects  its  expulsion.  In  some  instances,  only  a  part  of  the 
parasite  is  thus  expelled,  and,  if  the  head  should  be  retained,  it 
soon  reproduces  itself.  Hence  the  importance  of  the  directions 
already  given  in  this  lecture  for  passing  the  stools  after  such  a 
treatment  into  tepid  water  so  that  it  may  be  readily  determined 
whether  the  entire  worm,  including  the  head,  has  been  removed. 
Tapeworm  remedies  need  to  be  fresh  and  fully  active  in  order 
to  succeed. 

Probably  the  most  successful  of  all  the  different  remedies  is 
the  male  fern — filix  mas — and  a  very  efficient  and  convenient 
way  of  administering  it  is  in  capsules,  on  account  of  its  un- 
pleasant taste.  It  is  especially  eft'ective  when  given  in  milk, 
which  tapeworms  prefer  as  a  food.  The  drug  is  not  entirely 
safe,  and  cases  of  poisoning  from  it  are  on  record,  one  of  them 
fatal ;  but  it  is  believed  that  the  lethal  result  was  in  consequence 
of  the  fact  that  castor  oil  was  administered  with  it,  thus  greatly 
increasing  its  absorption  into  the  system.  No  cathartic  should 
be  administered  with  it,  but  two  hours  after  it  some  other  one 
than  castor  oil.  ' 

^Mlenever,  in  any  case,  the  examination  shows  that  the  head 
of  the  parasite  has  not  been  passed,  there  will  be  reason  to  ex- 
pect a  recurrence  of  all  the  symptoms  in  a  short  time ;  but  it  is 
better  to  wait  until  evidences  appear  that  the  worm  has  re- 
produced itself  before  repeating  the  administration  of  remedies 
to  expel  it.°  To  repeat  the  violent  course  of  remedies  required 
to  expel  a  tapeworm  within  a  few  days  is  never  desirable,  and 
it  is  particularly  -unsafe  to  repeat-  so  soon  a  full  dose  of  male 
fern. 

In  the  frcafincut  of  round  zcornis  santonin  is  the  only  drug 
that  need  be  considered.  Half-grain  doses  of  it  are  prepared 
in  troches,  which  are  now  official  in  the  United  States  Phar- 
macopeia. For  a  child  under  two  years,  one  of  these,  or  the 
same  dose  as  a  powder  with  sugar,  may  be  given  at  night,  and 


948  THE    GASTRO-INTESTINAL    CLINIC 

again  the  next  morning",  upon  an  empty  stomach,  followed  an 
hour  later  by  a  dose  of  castor  oil,  rhubarb,  or  calomel.  A 
child  five  years  old  will  need  doses  of  one  grain,  and  adults 
from  3  to  4  grains,  administered  in  the  same  way. 

The  effect  of  all  anthelmintics  is  much  enhanced  by  restrain- 
ing the  patient  to  the  simplest,  and  preferably  liquid,  food  for 
a  few  days,  before  the  remedy  is  begun,  and  you  should  see  to 
it  that  during  the  same  time  the  bowels  are  especially  open 
— that  there  are  at  least  two  soft  or  liquid  stools  daily. 

Tlic  treatment  of  seat-  or  thread-zvornis  requires  the  fre- 
quent irrigation  of  the  colon  with  some  mild  disinfectant  so- 
lution— it  matters  little  what  one,  so  that  it  be  mild  enough 
not  to  irritate  the  mucosa.  An  infusion  of  quassia  or  simple 
olive  oil  injected  every  few  days  for  several  weeks  has  often 
succeeded  in  my  own  experience.  In  female  children  es- 
pecially it  is  well  to  have  a  few  grains  of  zinc  ointment,  or  un- 
guentum  hydrargyri  cinerei,  smeared  about  the  anus  once  a 
day,  to  prevent  the  migration  of  the  worms  into  the  vagina. 
Weak  solutions  of  quinine,  or  boracic  acid,  etc.,  have  also 
proved  effective. 

In  stubborn  cases  the  administration  of  santonin  has  been 
recommended  as  directed  for  round  worms.  Whitaker,^  how- 
ever, doubts  the  efficiency  of  any  remedies  administered  by  the 
mouth,  but  insists  that  enemas  of  soapy  water,  after  a  pre- 
liminary irrigation  to  empty  the  colon  completely,  are  as  ef- 
ficient as  any  other.  He  advises  one  such  enema  every  week 
for  three  weeks. 

Since-  the  worms  inhabit  the  upper  colon  and  cecum,  as  well 
as  the  rectum,  it  is  important  that  the  enemas  should  be  caused 
to  pass  entirely  through  the  colon,  and  this  is  best  effected  by 
having  the  patient  either  in  the  knee-chest  position  during  the 
injection,  or  lying  on  the  left  side  for  a  short  time  at  first,  and 
afterward  on  the  right  side. 

'  Wood's  "  Reference  Handbook,"  vol.  vii,  p.  794,  New  York,  1889. 


BACTERIA_,    ETC.^    IN    THE    GASTRO-INTESTINAL    TRACT       949 

TRICHINA    SPIRALIS   AND   TRICHOCEPHALUS   DISPAR 

Trichina  occurs  frequently  in  pork — very  rarely  in  the  meat 
of  other  animals.  It  exists  in  two  forms  or  stages  of  its  de- 
velopment :  ( I )  in  a  sexually  mature  form,  when  its  habitat  is 
the»intestine,  and  (2)  in  a  larval  or  immature  form,  when  it  is 
found  in  the  muscles,  usually  encapsulated.  When  portions  of 
meat  containing  the  encapsulated  larvae  of  trichinae  are  eaten, 
the  latter  are  liberated  within  a  few  hours  after  reaching  the 
stomach,  by  the  opening  of  the  capsules,  and  develop  with  great 
rapidity.  By  the  end  of  forty  to  forty-eight  hours  the  imma- 
ture larvae  have  fully  matured  in  the  intestine,  and  impregnation 
of  the  females  takes  place.  The  birth  of  a  new  progeny  occurs 
by  the  end  of  a  week  from  impregnation,  and  in  two  weeks 
more  the  embryos  have  migrated  from  the  intestine  to  the 
muscles  of  the  infected  person. 

The  fully  developed  female  trichinae  are  3  to  4  mm.  long, 
while  the  males  are  only  half  so  long.  At  this  stage  the  para- 
site can  be  seen  by  the  unaided  eye. 

Illustrations  of  trichinae  are  shown  on  page  950. 

Trichinosis  is  the  name  given  to  the  acute  febrile  disease 
produced  by  these  parasites.  It  is  rather  a  disease  of  the  mus- 
cles than  of  the  gastro-intestinal  tract,  and  therefore  shall  be 
only  briefly  considered  here.  However,  a  few  days  after  eat- 
ing meat  infected  with  trichinae,  the  victim  is  likely  to  com- 
plain of  certain  indigestion  symptoms — loss  of  appetite, 
nausea,  vomiting,  and  diarrhea,  with  usually  pain  of  a  colicky 
kind,  besides  much  flatulency.  By  the  end  of  a  few  days,  or  a 
week  after  the  larvae  have  reached  the  muscles,  there  is  de- 
veloped fever  with  pains,  and  usually  decided  stiffness  in  the 
muscles  as  the  predominant  symptoms.  There  is  marked 
eosinophilia  during  the  acute  stage,  and  possibly  bronchitis, 
and  pneumonia.  Involvement  of  the  respiratory  muscles 
causes  a  marked  form  of  dyspnoea.  When  the  infection  is 
severe,  and  the  fever  high,  there  is  often  delirium.  Some- 
times oedema  of  the  face  and  eyelids  is  an  early  symptom. 


950 


THE    GASTRO-INTESTINAL   CLINIC 


The  diagnosis  must  be  made  from  typhoid  fever,  muscular 
rheumatism,  etc.,  and  may  be  established  with  an  approxima- 
tion to  positiveness  in  marked  cases  by  the  oedema  and  the  mus- 
cular symptoms — pain  and  stiffness — especially  when  dyspnoea 


^ 


•J'    •'^ 


Fig,    ho. — Trichina    spiralis  (after  Leuckardt);    a,  female;    b,  male  of 
intestinal  trichina;  c,  muscle-trichinae  in  capsule. 

results  from  involvement  of  the  respiratory  muscles;  but  the 
recognition  of  the  parasite  in  a  piece  of  excised  muscle  affords 
the  "only  certain  evidence  of  the  disease,  except  when  the  adult 
trichiucie  can  be  found  in  the  stools. 

The  mortality  from  the  disease  differs  widely  in  different 
epidemics — from  o  to  30  per  cent. 

Treatmeyit. — Meat,  especially  pork,  should  never  be  eaten 
raw,  or  insufficiently  cooked,  if  trichinae  and  teniae,  as  well  as 


BACTERIA^    ETC.^    IN    THE    GASTEO-INTESTINAL   TRACT        95 1 

Other  parasites  which  infest  the  flesh  of  animals,  are  to  be 
avoided. 

For  the  curative  treatment  of  an  attack  of  trichinosis  at  an 
early  stage,  while  there  is  still  a  probability  that  a  part  of  the 
parasites  remain  in  the  intestines,  the  most  effective  method  is 
prompt  and  energetic  cleansing  of  the  alimentary  canal  by 
purgatives  and  colon  douches,  followed  by  full  doses  of  intesti- 
nal antiseptics.     Santonin,  also,  has  often  proved  effective. 

When  the  migration  is  over,  and  the  muscles  have  been  fully 
infected,  there  is  little  to  be  done,  except  to  sustain  the  strength 
and  vital  powers  in  every  way  possible.     Meanwhile  you  will, 


Z^ 


Fig.  III. — Trichocephalus  dispar.      (From   "  Krankheiten  des  Darms  u. 
des  Bauchfells,"  von  Prof.  Dr.  C.  A.  Ewald.) 


of  course,  alleviate  the  pain  and  insomnia  by  anodynes  and 
emollient  local  applications.  The  open-air  treatment,  now  uni- 
versally recommended  and  largely  employed  for  tuberculosis, 
will  add  much  to  the  patient's  chances  in  the  combat  with  such 
an  inaccessible  enemy,  and  moderate  tonic  doses  of  quinine, 
iron,  etc.,  are  beneficial. 

Trichocephalus  Dispar. — This  parasite  frequently  occurs  in 
the  cecum  or  adjacent  parts  of  the  intestine,  but  produces  usu- 
ally few  or  no  symptoms.  Ewald  speaks  of  it  as  harmless, 
though  other  authors^  mention  that  diarrhea,  or  reflex  nervous 
symptoms,  may  sometimes  result  from  its  presence  in  man.  In- 
fection is  caused  by  taking  the  eggs  in  uncooked  food    or  in 


952  THE    GASTRO-INTESTINAL    CLINIC 

water.  Raw  fruit,  lettuce,  and  other  green  vegetables  are  es- 
pecially liable  to  convey  them  into  the  alimentary  canal  unless 
carefully  washed. 

The  parasite  is  4  to  5  cm.  long.  It  is  shown  in  the  illustra- 
tion on  page  943,  the  two  smaller  figures,  to  the  right  of  the 
large  one,  representing  the  worm,  life-size. 

*The  ova,  which  are  not  killed  by  either  cold  or  drying,  are 
of  a  peculiar  oval,  with  a  knobbed  projection  at  either  end. 


Fig.  112. — Ovum  of  Trichocephalus  dispar. 

They  are  about  50  f^  long,  of  a  brown  color,  and  have  a  hard 
shell.  They  develop  in  wet  earth  or  water,  but  very  slowly^ — in 
several  months.     An  illustration  of  one  of  them  is  here  given. 

The  trichocephalus  dispar,  or  more  frequently  its  eggs,  may 
be  recognized  in  the  stools  by  a  careful  microscopic  examina- 
tion. It  is  seldom,  however,  that  the  wonns  themselves  can 
be  found  in  the  stools. 

As  to  treatment,  various  anthelmintics  and  teniafuges  have 
been  used  successfully.  Male  fern  and  thymol  internally  are 
especially  recommended.  Douches  of  the  colon  with  antiseptic 
solutions  are  useful  adjuvants. 


LECTURE  LXXXI 

GASTRO^INTESTINAL   AFFECTIONS    IN 
RELATION    TO    OTHER   DISEASES 

A  FULL  and  adequate  discussion  of  the  interrelations  be- 
tween the  gastro-intestinal  tract  and  other  organs  or  systems, 
as  to  their  functions  and  diseases,  would  fill  a  large  volume 
alone.  But  they  call  for  some  consideration  here,  even 
though  it  must  be  less  extended  than  the  subject  demands. 
We  know  that  in  many  febrile  affections,  and  as  a  rule  in 
high  fever  from  any  cause,  the  digestion  is  disturbed,  the  ap- 
petite is  impaired,  and  the  tongue  heavily  coated;  constipation 
or  diarrhea  develops  in  most  cases,  and  nausea  and  vomiting 
may  occur  at  times  as  complications.  In  the  advanced  stages 
of  most  organic  diseases  the  digestive  functions  are  likely  to  be 
markedly  lowered,  and  in  certain  affections  of  the  skin,  in- 
cluding nearly  all  those  not  dependent  upon  local  irritations 
or  general  exogenous  infections,  the  intestinal  digestion  espe- 
cially is  usually  impaired  and  the  metabolism  deranged.  We 
know,  too,  that  derangements  of  the  functions  of  digestion 
and  assimilation  affect  directly  or  indirectly  all  the  other 
functions  of  the  body.  Thus  mu^ch  can  be  said  with  a  good 
degree  of  certainty,  but  when  we  go  further  and  seek  for  a 
definite  relation  between  the  diseases  of  other  organs  and  the 
amount  of  secretion  or  degree  of  motor  power  in  the  stomach, 
as  has  been  done,  we  often  meet  with  disappointment. 

No  such  uniform  relation  has  been  demonstrated  to  exist  be- 
tween any  of  the  gastro-intestinal  functions  and  the  different 
general  or  local  diseases  involving  other  parts,  especially  as  re- 
gards the  influence  of  these  diseases  upon  such  functions. 
The  nearest  approach  to  such  uniformity  is  the  tendency  of 

953 


954  THE    GASTRO-INTESTINAL    CLINIC 

advanced  disease  in  the  heart  and  arteries  to  lower  both  the 
secretory  and  motor  fnnctions  of  the  digestive  organs;  and 
also  the  tendency  of  movable  kidney  as  well  as  some  of  the 
other  ptoses,  gall-bladder  affections,  etc.,  to  excite  the  gastric 
glands  and  cause  hyperchlorhydria  reflexly.  Again  defeca- 
tion is  likely  to  be  disturbed  in  either  one  way  or  the  other  in 
nearly  every  serious  general  disease,  as  well  as  in  a  large  pro- 
portion of  the  local  ones,  and  most  frequently  by  depressing 
it,  producing  constipation.  Diarrhea  is  more  common  in 
typhoid  fever  and  in  some  of  the  more  severe  forms  of  sep- 
ticaemia, and  often  results  secondarily  from  the  irritation  pro- 
duced by  hard  fecal  masses  in  chronic  constipation. 

The  foregoing  general  statement  must  suffice  with  regard  to 
the  relation  of  most  other  diseases  to  those  of  the  stomach  and 
intestines  and  to  the  functions  of  the  digestive  system. 

However,  the  relation  of  the  maladies  of  a  few  of  the  prin- 
cipal organs  and  systems  to  the  digestive  functions  deserves 
special  mention. 

ANiEMIA  AND   CHLOROSIS 

The  results  of  experiments  and  observations  are  scarcely 
more  uniform  here. 

Influence  of  Displacements  of  the  Viscera  upon  the  Blood. 

— There  is,  however,  a  preponderance  of  evidence  to  the  fact 
that  chlorosis  is  unusually  prevalent  in  girls  who  have  displace- 
ments of  the  stomach  or  other  viscera — gastroptosis,  or 
splanchnoptosis.  In  these  cases  there  should  certainly  be  a 
particularly  careful  examination  of  the  abdomen  to  determine 
the  position  of  the  viscera,  so  that  displacements  may  be 
remedied.  But  in  chlorosis,  too,  the  proportion  of  HCl  may 
vary  much  and  be  normal,  excessive,  or  deficient.  Riegel  con- 
siders that  in  simple  chlorosis  the  secretion  and  motor  power  of 
the  stomach  are  not  as  a  rule  decreased — more  frequently,  in- 
deed, increased. 

On  the  other  hand,  in  the  anaemias,  although  here  also  the 


RELATION    OF   GASTRO-INTESTINAL    TO    OTHER  DISEASES         955 

findings  have  been  various,  and  no  uniform  rule  holds,  there  is 
a  rather  greater  probability  that  the  production  of  HCl  will  be 
diminished,  especially  when  it  is  remembered  that  there  is  a 
peculiarly  close  relation  between  some  of  the  more  profound 
types  of  anaemia  and  the  total  absence  of  secretion  in  the 
stomach — achylia  gastrica. 

The  motor  function  of  the  stomach  is  rarely  under  normal  in 
either  ansemia  or  chlorosis,  and  it  occasionally  happens,  espe- 
cially in  the  latter,  that  there  is  a  marked  excess  of  HCl. 

Influence  of  Constipation  and  Other  Gastro-intestinal  Affec- 
tions.— Judging  from  my  own  experience,  constipation  is  al- 
most constantly  associated  with  chlorosis,  and  is  very  likely  to 
complicate  ansemia.  You  should  always  remember,  however, 
that  constipation  may  easily  pass  over  into  diarrhea  by  a  proc- 
ess already  explained. 

Gastric  and  intestinal  affections  nearly  all  tend  finally  to 
impair  the  crasis  of  the  blood.  Dyspeptics  rarely  have  a  good 
healthy  color. 

THE   RELATION  OF  THE   GASTRO-INTESTINAL   FUNC- 
TIONS  TO   TUBERCULOSIS 

Since  tuberculosis  is  an  infectious  disease  from  which 
the  healthy  and  robust  are  comparatively  immune,  and  to  which 
the  debilitated  are  especially  prone,  you  should  readily  under- 
stand how  any  seriously  depressing  affection  in  the  gastro- 
intestinal tract  can  pave  the  way  for  it.  HCl  has  been  shown 
to  exert  a  decided  influence  in  inhibiting  the  development  of 
the  tubercular  bacilli,  and  it  is  probable  that  persons  whose 
gastric  glands  secrete  abundantly  are  in  less  danger  of  becom- 
ing infected  through  their  food  or  drink,  but  are  not  appar- 
ently in  much  less  danger  of  infection  through  the  respiratory 
tract,  though  some  recent  contributions  uphold  the  view  that 
the  infection  always  occurs  through  absorption,  from  the  in- 
testinal mucosa,  being  carried  by  the  blood  and  lymph  to  the 
lungs. 


956  THE    GASTRO-INTESTINAL    CLINIC 

A  paper  entitled  Stomach  Conditions  in  Early  Tuberculosis, 
'read  by  me  before  the  American  Climatological  Association  in 
Washington  in  May,  1900,  and  subsecjuently  published  in  the 
Philadelphia  Medical  Journal,  considered  fully  the  relations  of 
this  most  important  disease  to  the  digestive  functions,  and  I 
here  append  the  larger  part  of  it : 

Impaired  Digestion  Conducive  to  Tuberculosis "  In  what 

has  been  incorrectly  styled  the  pretuberculous,  but  should  be 
called  the  incipient,  stage  of  consumption,  the  most  noticeable 
symptoms  are  often  those  of  flatulent  dyspepsia,  with  eructa- 
tions and  pyrosis  or  heartburn,  with  or  without  gastric  pain, 
nausea,  and  even  stubborn  vomiting.  These  are  sometimes 
symptoms  merely  of  a  lowered  nerve-tone,  and  at  other  times 
evidences  of  actual  gastric  involvement. 

"  All  the  possible  affections  of  the  stomach  may,  of  course, 
precede  tuberculosis.  Indeed,  its  development  must  be  favored 
by  gastric  dilatation,  the  various  forms  of  chronic  gastritis,  and 
a  failure  or  persistently  depressed  activity  of  the  peptic  glands, 
from  whatever  cause,  nutrition  being  lowered  in  this  way  to  a 
degree  which  may  render  infection  possible. 

"  Moreover,  it  is  probable  that,  contrary  to  general  belief, 
hypersthenic  conditions  in  the  stomach,  such  as  hyperchlor- 
hydria  and  acid  gastric  catarrh,  are  quite  as  compatible  with 
tubercular  infection  through  the  lungs  as  are  the  asthenic  types 
of  gastric  disease.  For  it  is  now  known  that  a  large  propor- 
tion of  the  cases  of  early  phthisis — a  preponderance  of  them, 
according  to  some  observers — has  an  excessive  secretion  of 
HCl. 

Free  HCl  Often  Present — "  Though  not  a  very  large  num- 
ber of  reports  of  analyses  of  the  stomach  contents  in  the  early 
stages  of  tuberculosis  are  to  be  found  in  medical  literature — 
and  this  question,  therefore,  cannot,  be  said  to  have  been  posi- 
tively decided — the  evidence  so  far  available  points  to  the  con- 
clusion that,  except  in  advanced  cases  with  continuous  fever, 
there  is  at  least  quite  as  likely  to  be  an  abundant  secretion  as  a 
deficiency  of  HCl  in  the  stomach. 


RELATION    OF   GASTRO-INTESTINAL   TO   OTHER   DISEASES         957 

"  Van  Valzah  and  Nisbet/  in  47  cases  of  incipient  phthisis, 
found  in  10  no  signs  or  symptoms  of  any  gastric  derange- 
ment. Three  out  of  the  same  series  had  chronic  gastritis,  with 
an  absence  of  free  HCl,  a  diminished  proportion  of  combined 
HCl,  etc.  In  18  of  the  cases  there  were  traces  only  of  free 
HCl  and  diminution  of  secretion  otherwise.  In  13  of  this  last 
number  there  was  mild,  and  in  5  severe,  stagnation,  with  fer- 
mentation. 

"  Among  the  16  remaining  of  the  47  cases,  3  were  found  to 
have  acid  gastric  catarrh — i.  e.,  the  sthenic  form  of  chronic 
gastritis,  with  an  augmented  secretion  of  HCl;  7  had  the  same 
acid  in  excess,  with  motor  insufficiency,  stagnation,  and  de- 
layed evacuation;  and  in  the  other  6  there  was  also  hyperchlor- 
hydria,  with  fermentation  in  all;  while  in  2  of  them  the  stom- 
ach was  unable  to  empty  itself  even  during  the  night. 

"  In  26  cases,  first  examined  by  the  same  authors  during  the 
stage  of  consolidation,  4  were  normal  as  to  gastric  juice,  5  had 
chronic  asthenic  gastritis,  one  had  a  trace  only  of  free  HCl, 
and  in  13  the  secretion  was  variable,  which  means  that  some- 
times it  was  in  excess,  and  at  other  times  normal  or  deficient. 

"  Thus  in  47  incipient  cases  there  were  26,  or  55  per  cent., 
with  either  a  normal  or  overacid  gastric  juice;  and  of  the  26  in 
the  stage  of  consolidation,  in  4,  or  15  per  cent.,  the  secretion 
was  normal  constantly,  and  in  50  per  cent,  more  it  was  variable, 
that  is  normal  or  above,  a  part  of  the  time.  In  65  per  cent., 
therefore,  of  the  y^)  comparatively  early  cases  studied  by  Van 
Valzah  and  Nisbet,  the  secretion  of  HCl  was  normal,  or  above, 
at  least  a  part  of  the  time. 

The  Motor  Function  Mostly  Depressed — "  Riegel  ^  quotes 
Klemperer  as  thus  summing  up  the  results  of  his  observations 
in  14  cases,  10  of  early  and  4  of  more  advanced  phthisis.  In 
the  beginning  the  secretory  capacity  of  the  stomach  was  mostly 
increased,  often  normal,   seldom  lowered ;  in  the  final  stage 

1  "  The  Diseases  of  the  Stomach,"  Philadelphia,  W.  B.  Saunders  &  Co., 
1898  ;  page  646,  et  seq. 

2  "  Erkranktingen  des  Magens,"  Wien,  Alfred  Hoelder,  1897,  pp.  946-947. 


958  THE    GASTRO-INTESTINAL    CLINIC 

markedly  lessened.  Klemperer  found,  however,  that  in  all 
the  forms  of  dyspepsia  associated  with  tuberculosis  the  motor 
function  of  the  stomach  was  depressed. 

"  Brieger/  cjuoted  by  Riegel,  studied  64  cases  of  tubercu- 
losis, all  except  6  of  which  were  in  a  more  or  less  advanced 
stag-e.  In  such  a  series  there  would  naturally  be  a  preponder- 
ance of  depression  in  all  the  gastric  functions.  Still  in  16  per 
cent,  of  even  the  more  severe  cases,  Brieger  found  a  normal 
condition  of  the  gastric  juice,  while  the  same  was  observed  in 
33  per  cent,  of  the  cases  classed  as  moderately  severe.  In  the 
4  incipient  cases,  he  found  2  with  normal  secretion,  and  2  with 
disturbed  chem.ism,  the  inference  being  that  in  the  latter  there 
was  a  variable  condition. 

"  Riegel  -  states  that  the  results  of  his  own  observations  ac- 
cord in  the  main  with  those  of  Klemperer  and  Brieger. 

"  Croner  ^  in  36  cases  of  early  phthisis  found  in  only  5  a 
complete  failure  of  HCl.  The  total  acidity  varied  from  21  to 
80,  but  it  was  in  most  cases  normal.* 

"  Unforunately  for  the  cause  of  medical  science,  and  for  the 
best  interests  of  patients,  physicians  in  general  practice  rarely 
make,  themselves,  or  have  made,  analyses  of  the  stomach  con- 
tents except  when  cancer  is  suspected,  and  the  pulmonary 
specialists,  I  fear,  have  been  in  the  past  almost  equally  in- 
different to  the  modern  exact  methods  of  studying  the  gastric 
functions. 

Frequent  Intolerance  of  the  Usual  Remedies. — "  The  series 

1  Loc.  cit. 

^Loc.  cit. 

^Deutsche  Med.   Woch.,  1898,  No.  48. 

4  At  the  Pottenger  Sanatorium  for  Diseases  of  the  Throat  and  Lungs  at 
Monrovia,  Cal.,  it  is  now  the  rule  to  test  the  feces  in  all  cases  having 
serious  gastro-intestinal  complications,  and  also  the  stomach  contents  in 
such  cases  when  a  tube  can  be  safely  used.  In  a  recent  series  of  55  tuber- 
culous cases  there,  of  11  in  the  first  stage  3  showed  by  the  Mintz  method 
free  HCl  to  the  amount  of  40  or  more,  the  remainder  being  below  that 
figure  ;  of  the  4  in  the  second  stage  free  HCl  was  less  than  40  in  all  ;  and 
the  remaining  40  cases,  all  in  the  third  stage,  showed  36  with  free  HCl, 
under  40,  4  with  free  HCl  over  40  and  one  of  these  64,  which  was  the  only 
one  in  the  whole  series  over  60. 


RELATION    OF    GASTRO-INTESTINAL   TO    OTHER   DISEASES         Qt^Q 

of  cases  reported  by  Van  Valzah  and  Nisbet,  by  Brieo-er  and 
by  Klemperer,  show  that  in  early  tuberculosis  there  is  present 
very  frequently — and  probably  in  a  majority  of  cases — a  con- 
dition of  the  peptic  glands  which  contra-indicates  the  adminis- 
tration of  any  considerable  doses,  by  the  stomach  at  least,  of 
highly  stimulating  remedies,  such  as  carbolic  acid,  creosote 
and  its  derivatives,  the  mineral  acids,  and  most  of  the  familiar 
stomachics.  That  is,  in  these  cases  when  the  gastric  function 
is  not  entirely  normal,  there  is  usually  either  an  excess  of  HCl, 
or  a  very  impressionable  and  variable  condition  of  the  secre- 
tion— a  condition  in  which  the  exhibition  of  stimulating  drugs 
produces  harmful  irritation,  resulting  often  in  hyperchlor- 
hydria,  or  acid  gastric  catarrh,  which  complicates  the  treat- 
ment of  the  tuberculosis  and  lessens  the  prospects  of  cure. 
Riegel's  experience  agrees  with  that  of  the  authors  cited,  and 
my  own  case  well  illustrates  the  point  just  made,  besides  show- 
ing how  tuberculosis  for  a  long  time  may  masquerade  in  the 
guise  of  a  stomach  trouble. 

"  In  the  light  of  these  facts,  it  is  easy  to  understand  why 
such  directly  opposite  views  are  held  by  clinicians  of  equal 
ability  as  to  the  value  of  large  doses  of  creosote  and  of  other 
irritant  drugs  in  tuberculosis.  Whether  the  remedy  does  good 
or  harm  depends  mainly  upon  the  condition  of  the  stomach, 
and,  it  not  having  become  yet  the  settled  practice,  as  it  ought 
to  be,  always  to  ascertain  the  state  of  the  gastric  functions  be- 
fore instituting  active  drug  treatment  in  any  chronic  disease,  a 
confusing  contrariety  of  results  follows  such  modes  of  treat- 
ment. 

"  For  exactly  the  same  reason  the  profession  is  divided  as 
to  the  value  of  cod-liver  oil  in  pulmonary  phthisis.  Recent  ex- 
periments prove  that  the  oils  markedly  lessen  the  secretion  of 
HCl  in  the  stomach.^  In  the  cases,  therefore,  in  which  the 
gastric  functions  are  almost  always  depressed,  as  in  the  later 
stages  of  phthisis,  cod-liver  oil,  or  much  fat  of  any  kind,  im- 

iBachman,  "  Experimentelle  Stttdien  iiber  die  diatetische  Behandlung 
bei  Su-pev&ciditat,"  A rc/a'v/.   Verdauungskrankheiten,  B.  v.,  Hft.  3. 


960  THE    GASTRO-INTESTINAL    CLINIC 

pairs  digestion  and  injures  the  patient;  whereas,  in  the  cases  of 
hyperchlorhydria,  which  are  so  often  found  in  the  earlier 
stages,  the  same  remedy  exerts  a  double  influence  for  good, 
since  here  it  tends  to  correct  the  injurious  hypersecretion  at 
the  same  time  that  it  helps  to  fatten  and  strengthen  the  patient. 
In  ^e  cases  between  these  extremes — cases  in  which  there  is  a 
nearly  normal  gastric  secretion — a  moderate  amount  of  oil  may 
prove  helpful  for  a  time,  and  by  means  of  an  occasional 
analysis  of  the  stomach  contents  to  see  when  it  has  begun  to 
depress  secretion  unduly,  advantage  may  safely  be  taken  of  its 
valuable  medicinal  and  nutrient  qualities. 

"  Let  me  turn  aside  right  here  to  advise  that,  in  doubtful 
cases,  in  which  an  analysis  of  the  stomach-contents  is  not  prac- 
ticable, as  well  as  in  cases  in  which  the  gastric  juice  has  been 
found  to  be  about  normal,  it  would  be  well  to  combine  creo- 
sote or  one  of  its  congeners  with  cod-liver  oil,  so  as  to  have  the 
stimulating  properties  of  the  former  neutralize  the  depressing 
influence  of  the  latter  upon  the  gastric  glands. 

Need  of  Strengthening  the  Motor  Function. — "  It  is  gen- 
erally conceded  that  the  motor  function  of  the  stomach,  which 
is  always  seriously  lowered  in  advanced  phthisis,  is  very  apt 
to  be  depressed  somewhat  in  even  the  earlier  stages.  That  is, 
the  muscular  walls  of  the  organ  lose  their  tone,  and  there  re- 
sults a  tardy  evacuation  of  the  contents,  with  consequent  stag- 
nation and  fermentation.  This  weakened  motility  must  be 
overcome  before  tuberculous  patients  can  get  well. 

"  Drugs  are  of  little  avail  for  this  condition.  *  *  *  We 
should  avoid  in  such  cases  overloading  the  stomach,  and  little 
or  no  liquids  should  be  taken  with  the  meals.  *  *  *  Massage  of 
the  abdomen  can  do  great  good,  except  when  the  gastric  glands 
are  irritable  and  inclined  to  overaction;  then  it  can  overstim- 
ulate  and  do  much  harm,  as  has  been  pointed  out  by  me  in  a 
previous  paper.^  Intragastric  faradism  is  also  most  helpful, 
but  must  be  used  with  discretion. 

^Massage  of  the  Abdomen,  by  Boardman  Reed,  M.  D.,  Internat.  Med. 
Mag.,  January,  1898. 


RELATION    OF   GASTRO-INTESTINAL   TO   OTHER   DISEASES         961 

"  The  points  emphasized  in  this  paper  may  be  thus  sum- 
marized : 

Conclusions — i.  "  In  early  tuberculosis,  the  secretion  of 
HCl  in  the  stomach  is  very  frequently  excessive,  the  peptic 
glands  being  in  a  condition  of  irritability,  which  causes  stimu- 
lant remedies  of  the  creosote  class  to  disagree  and  act  inju- 
riously. 

2.  "  Oils  tend  to  depress  the  secretory  function  of  the  stom- 
ach, and  in  consequence,  cod-liver  oil  is  likely  to  help  the  cases 
which  drugs  of  the  creosote  class  hurt;  but,  on  the  other  hand, 
hurts  the  cases  in  which  the  gastric  secretion  is  inactive,  the 
very  one  in  which  creosote  and  the  like  often  do  good. 

3.  "  Therefore  it  ought  to  be  the  rule  to  ascertain  the  condi- 
tion of  the  secretory  function  of  the  stomach  before  pushing 
either  class  of  remedies. 

4.  "  When  analysis  of  the  gastric  contents  cannot  be 
made,  it  is  safer  to  combine  creosote  with  cod-liver  oil,  so 
as  to  let  one  neutralize  the  other  in  its  influence  upon  the 
stomach. 

5.  "  The  motor  function  is  very  generally  depressed  in  tuber- 
culosis, and  must  be  restored  before  a  cure  can  be  brought 
about.  Drugs  avail  little  in  this  direction,  but  diet,  exercise,^ 
especially  in  the  open  air,  faradism,  and  abdominal  massage — 
except  when  hyperchlorhydria  complicates — are  all  valuable 
means  of  effecting  the  result." 

1  Experience  at  the  Pottenger  Sanatorium,  in  which  more  cases  of 
tuberculosis  are  treated  than  in  any  other  private  institution  in  America, 
has  seemed  to  demonstrate  that  much  exercise  is  not  conducive  to  the 
cure  of  such  cases.  Only  the  gentler  forms  of  exercise  are  encouraged 
there  for  even  patients  in  the  early  stage,  while  advanced  cases  are  con- 
fined to  bed  either  entirely  in  freely  ventilated  tent  cottages,  virtually  in 
the  open  air  constantly,  or  kept  at  rest  the  larger  part  of  the  time  in  such 
cottages.  Much  attention  is  given  to  the  selection  of  a  careful  dietary 
suited  to  the  needs  of  each  patient  as  shown  by  examinations  of  the 
stomach  contents,  feces,  etc  ,  and  appropriate  doses  of  tuberculin  have 
proved  conducive  to  the  cure  in  most  of  the  cases.  My  regular  visits  to 
that  institution  in  the  capacity  of  consulting  gastro-enterologist,  have 
enabled  me  to  bear  emphatic  testimony  on  these  points.  B.  R. 


962  THE    GASTRO-INTESTINAL    CLINIC 

CATARRHAL  AFFECTIONS  OF  THE   RESPIRATORY  TRACT 

Specialists  in  diseases  of  the  nose,  throat,  etc.,  are  coming 
more  and  more  to  the  conviction  that  the  catarrhal  affections 
of  this  region,  as  well  as  of  the  bronchial  tubes,  are  determined 
largely  by  a  faulty  metabolism.  The  chief  predisposing  condi- 
tion is  what  was  formerly  known  as  the  uric  acid  diathesis,  an 
obscure  vice  of  nutrition  due  in  part  to  inheritance,  and  in  part 
to  eating  excessively,  especially  of  meats  and  sweets,  by  per- 
sons who  lead  a  sedentary  life  and  exercise  little — i.  e.,  a  con- 
dition of  suboxidation.  My  own  observations  have  convinced 
me  that  this  explanation  of  the  aetiology  of  such  catarrhs  has 
much  in  its  favor  and  have  led  to  the  suspicion  that  the  mucous 
membranes  may  have  for  one  of  their  functions  the  excretion 
of  certain  of  the  products  of  a  faulty  metabolism. 

I  have  seen  numerous  cases  of  chronic  nasopharyngeal 
catarrh,  as  well  as  of  chronic  bronchitis,  which  were  not  only 
associated  with  indig'estion  and  lithsemia,  but  could  only  be 
relieved  or  improved  by  remedies  which  favored  the  elimina- 
tion of  the  uratic  products,  xanthin  bases,  etc.,  though  some- 
times the  combination  of  such  remedies — chiefly  alkalies — 
with  antiseptics  like  the  benzoates,  salicylates,  etc.,  proved  still 
more  effective. 

NERVOUS   DERANGEMENTS,    NEURASTHENIA, 
INSOMNIA,    ETC. 

The  sympathy  between  the  digestive  and  nervous  systems  is 
particularly  marked. 

Neurasthenia. — It  is  certain  that  all  the  forms  and  grades 
of  nerve  weakness  or  depression — neurasthenia — tend  strongly 
to  derange  the  digestive  functions  and  metabolism,  and  it  is  no 
less  a  fact  that  diseases  of  the  stomach  and  intestines,  as  well 
as  most  of  the  more  serious  disturbances  of  the  digestion  and 
assimilation,  influence  adversely  the  nervous  functions  so  that 
a  vicious  circle  is  formed.  They  impair  sleep,  producing  often 
insomnia,  lower  the  capacity  for  sustained  physical  or  mental 


RELATION    OF  GASTRO-INTESTINAL  TO   OTHER  DISEASES    963 

effort,  and  develop  an  irritability  of  temper.  These  effects  are 
in  some  instances  due  to  a  reflex  irritation  conveyed  to  the 
nervous  centers,  and  in  others,  to  an  autotoxic  influence  upon 
those  centers  and  the  nerve  structures  generally  through  an 
impoverishment  or  depravation  of  the  blood. 

Insomnia  is  particularly  often  dependent  upon  some  form  of 
indigestion.  Any  of  the  painful  gastro-intestinal  diseases,  such 
as  cancer,  ulcer,  colic,  or  even  marked  flatulency,  will  naturally 
disturb  or  wholly  prevent  the  sleep  by  the  actual  pain  or  dis- 
comfort produced  by  them.  But  you  should  not  overlook  the 
curious  and  interesting  fact  that  an  excess  of  HCl  in  the  gas- 
tric juice — hyperchlorhydria — will  often  greatly  impair  the 
sleep,  even  when  it  gives  rise  to  no  pain  or  conscious  discomfort 
in  the  stomach.  So  common  is  this  that  in  any  case  of  stub- 
born insomnia,  not  due  to  pain  or  other  manifest  cause,  }^ou 
should  test  the  stomach  contents  to  see  if  there  is  not  an  ex- 
cess of  HCl,  or  if  this  cannot  be  done,  try  the  effect  of  one  or 
two  teaspoonfuls  of  sodium  bicarbonate,  administered,  well 
diluted,  at  bedtime.  It  will  sometimes,  in  such  cases,  accom- 
plish much  more  than  the  usual  hypnotics. 

Auto-intoxication,  resulting  indirectly  from  the  more  se- 
rious and  persistent  derangements  of  digestion,  besides  being 
able  to  disturb  the  nervous  functions  in  the  ways  mentioned,  is 
capable,  doubtless,  also  of  injuring  ultimately  the  nerve  struc- 
tures themselves,  and  setting  up  organic  lesions  in  the  nervous 
system,  just  as  it  can  in  the  circulatory  system  and  the  kid- 
neys. 

DISEASES   OF   THE   LIVER   AND   GENITAL   ORGANS 

The  liver  is  another  organ  which  can  be  damaged  seriously 
by  prolonged  gastro-intestinal  disease.  There  is  no  longer 
room  for  doubt  that  various  hepatic  lesions,  including  a  form 
of  cirrhosis,  can  have  such  an  origin.  Boix  has  written  a  book 
entitled  "  The  Liver  of  Dyspeptics,"  in  which  this  subject  is 
discussed  at  much  length.^ 

^  G.  P.  Putnam's  Sons,  New  York,  1897. 


964  THE    GASTRO-INTESTINAL    CLINIC 

Conversely,  too,  hepatic  affections  can  greatly  derange  the 
functions  of  both  the  stomach  and  intestines.  Colecystitis  and 
colelithiasis  are  particularly  likely  to  give  rise  to  dyspeptic 
S}Tnptoms  and  many  a  sufferer  from  one  or  both  of  them  has 
been  dosed  ad  nauscmn  for  "  stomach  trouble,"  very  often,  too, 
with  hydrochloric  acid  and  pepsin,  when,  as  usual  in  the  earlier 
stages  at  least,  of  such  cases,  there  has  been  a  large  excess  in- 
stead of  a  deficiency  of  that  acid  in  the  gastric  juice.  But 
space  is  lacking  for  as  full  a  consideration  of  these  interesting 
relations  of  the  stomach  and  liver  as  their  importance  deserves. 

The  interrelations  between  the  stomach  and  intestines  on  the 
one  hand,  and  the  genital  organs  on  the  other,  are  very  inti- 
mate. The  functions  of  the  one  are  rarely  much  deranged 
without  some  sympathetic  disturbance  in  those  of  the  other. 
This  is  as  might  be  expected,  considering  the  fact  that  the 
nerve  supply  of  the  two  systems  is  in  large  part  from  closely 
associated  centers — particularly  the  vaso-motor  nerves,  which 
control  the  caliber  of  the  arterioles  in  each  set  of  organs,  and 
thus  regulate  the  blood  supply  to  them. 

I  have  already  referred  (Lecture  XLIX.)  to  the  marked  ef- 
fect of  movable  kidney  in  setting  up  hyperchlorhydria  by  re- 
flexly  exciting  gastric  secretion,  and  have  dwelt  at  some  length, 
in  Lecture  XLIIL,  upon  the  frequent  dependence  of  pelvic 
troubles,  such  as  displacements  of  the  uterus  and  ovaries,  upon 
gastroptosis  or  enteroptosis.  Then,  hyperchlorhydria  by  the 
irritating  effect  of  the  excessive  acid  upon  the  intestinal  mu- 
cosa is  a  prolific  cause  of  flatulence,  and  I  have  seen  many  cases 
in  both  sexes  in  which  flatulence  has  reflexly  irritated  the 
sexual  organs,  producing  at  night  painful  erections  in  men, 
with  unrefreshing  sleep,  and  analogous  disturbances  in  women. 
Most  gastrologists  have  observed  that  women  having  stomach 
trouble  will  often  secrete  during  their  menstrual  periods  more 
or  less  HCl  than  usual;  there  is  no  uniformity  as  to  the  kind 
or  amount  of  the  aberration  from  the  normal,  but  it  may  be  in 
either  direction,  and  either  slight  or  very  marked.  The  fact 
is  well  known  that  various  forms  of  gastric  derangement  may 


RELATION    OF   GASTRO-INTESTINAL    TO    OTHER   DISEASES         965 

result  from  disease  or  displacement  of  the  uterus  or  ovaries- 
but  it  is  not  so  well  known  that  disease  of  the  prostate  gland 
in  men  may  disturb  the  digestion/ 

DISEASES   OF   THE    HEART 

Cardiac  affections,  involving  a  lowered  blood  pressure — /.  e., 
valvular  defects  not  well  compensated — and  dilatation  of  the 
heart,  or  decided  weakness  of  the  cardiac  muscle  from  any 
cause,  generally  lessen  the  secretion  of  HCl  in  the  stomach, 
and  of  the  bile  in  consequence  of  the  stasis,  with  resulting  slow 
digestion  and  constipation. 

Riegel  notes  that  in  these  cases  the  stomach  often  secretes 
sufficiently  for  the  small  test  breakfast,  but  not  enough  for  the 
heartier  test  dinner,  and  I  have  observed  that  in  analogous  con- 
ditions, resulting  from  neurasthenia,  there  may  be  sufficient 
secretion  in  the  morning,  when  the  patient  is  rested,  but  not 
enough  in  the  latter  part  of  the  day,  when  he  has  become 
fatigued.  These  facts  should  teach  us  something  as  to  the 
management  of  such  patients.  It  is  a  manifest  inference  that 
numerous  small  feedings  will  best  nourish  patients  with  fail- 
ing circulation,  and  that  more  rest — less  exhaustion  of  the  vital 
force  by  the  usual  activities — will  do  most  for  neurasthenics. 
Flatulence  directly  disturbs  the  heart,  causing  palpitation,  ir- 
regular pulse,  etc.,  besides  probably  reflexly  increasing  the 
blood  pressure  according  to  a  series  of  observations  by  me  in 
the  succeeding  lecture — Lecture  LXXXII. 

Quite  as  interesting  and  worthy  of  study  as  the  effects  of 
other  diseases  upon  the  digestive  processes  are  the  effects  of 
impaired  digestion  and  faulty  assimilation  upon  the  other 
functions,  and  even  upon  the  tissues  of  the  organism. 

1  At  the  meeting  of  the  American  Medical  Association  in  Boston  June  5 
to  8,  1906,  a  physician  from  Memphis,  Tenn.,  remarked  in  substance  dur- 
ing the  discussion  of  a  paper  before  the  section  of  Practice  of  Medicine 
that  we  hear  much  of  hepatic  insufficiency,  renal  insufficiency,  cardiac  in- 
sufficiency, etc.,  but  that  gastro-intestinal  insufficiency  is  really  the  alma 
mater  of  all  the  other  insufficiencies.  This  is  to  a  very  large  extent  true, 
and  it  is  a  truth  very  strikingly  expressed. 


966  THE    GASTRO-INTESTINAL    CLINIC 

How  Digestive  Faults  Injure  the  Heart, — Certain  of  the 
products  of  a  faulty  metabolism  tend  to  increase  the  labor  of 
the  heart  by  contracting  and  probably  also  roughening  the 
inner  coats  of  the  smaller  arteries  and  capillary  vessels  gen- 
erally, besides  increasing  the  viscosity  of  the  blood  as  claimed 
by  Haig.  Croftan  ^  has  reported  experiments  proving  that 
some  of  the  xanthin  bases  can  produce  both  hypertrophy  of  the 
heart,  and  chronic  nephritis  in  animals.  Haig  has  reported 
many  clinical  observations  which  tend  to  show  increased 
arterial  tension  under  dietetic  methods  which  produce  an  ex- 
cess 0/  uric  acid,  and  he  has  built  upon  these  observations  his 
well-known  theory  as  to  the  toxic  effects  of  uric  acid  upon  the 
nervous  system  and  various  organs.  His  results  are  now  ex- 
plicable on  the  hypothesis  that  the  alloxuric  or  xanthin  bases, 
substances  of  the  uratic  group,  and  probably  not  uric  acid  it- 
self, were  responsible  for  the  results  observed  by  him. 

To  go  a  step  further  back,  the  digestive  processes  need  to  be 
perfectly  performed  in  order  that  the  metabolism  may  be  com- 
plete, though  when  one  overeats  and  underexercises,  there  may 
be,  easily  enough,  a  disturbed  metabolism  in  spite  of  a  naturally 
sound  digestion.  An  excessive  secretion  of  HCl  (hyperchlor- 
hydria)  tends  to  exercise  a  very  irritating  effect  upon  the  mu- 
cosa of  the  intestines,  with  the  result  in  many  cases  of  setting 
up  catarrhal  inflammation,  with  constipation,  etc.  Few  things 
tend  more  surely  to  produce  a  deranged  metabolism,  with  the 
production  of  excessive  fermentation  and  putrefaction,  than 
intestinal  catarrh  and  a  sluggish  intestinal  peristalsis.  These 
conditions  increase  enormously  the  absorption  of  toxins  from 
the  intestinal  tract. 

You  will  readily  understand  that  what  is  true  of  hyperchlor- 
hydria  is  still  more  true  of  the  same  condition  of  HCl  excess, 
plus  an  open  sore  in  the  stomach  or  duodenum,  such  as  we  have 
in  the  round  or  peptic  ulcer  of  these  parts.  Still  greater  and 
more  profound  is  the  disturbance  of  metabolism  in  such  a  se- 
rious disease  as  cancer  of  the  stomach,  pancreas,  or  any  other 

'^Joiir.  A))icr   Med.  Assji  ,  July  8,  1S99 


RELATION    OF   GASTRO-INTESTINAL   TO    OTHER    DISEASES         967 

of  the  digestive  organs.  The  same  is  true  in  the  case  of  a 
very  markedly  weakened  motor  power  in  either  the  stomach  or 
intestines,  or  the  downward  displacement  of  any  of  the  viscera. 
All  these  diseases  and  derangements  seriously  affect  nutrition 
and  impair  the  metabolism  with  a  double  resulting  injury  to  the 
heart — an  impairment  of  the  nutrition  of  its  muscular  fibers 
and  an  increase  of  its  work,  in  very  many  cases,  through  the 
contraction  of  the  smaller  vessels  throughout  the  body  by  the 
toxic  products  of  incomplete  metabolism  as  above  explained. 

When  there  exists  for  long  periods  a  marked  deficiency  of 
secretion  on  the  part  of  any  of  the  important  digestive  glands, 
whether  this  deficiency  coincides  with  a  catarrhal  process  in 
the  mucous  membrane  or  depends  merely  upon  nervous  or 
reflex  influences,  the  metabolism  may  be  affected  almost  as 
injuriously  as  in  the  cases  of  HCl  excess.  A  deficiency  of  the 
gastric  juice  is  very  frequently  found  with  an  excess  of  indican 
in  the  urine,  and  though  my  own  experience  has  been  that 
hyperchlorhydria  most  frequently  coincides  with  indicanuria,  I 
can  well  believe  that  either  departure  from  the  normal,  when 
pronounced,  can  so  far  derange  intestinal  digestion  as  to  in- 
crease fermentation  and  putrefaction  in  that  part  of  the  ali- 
mentary canal.  Increased  fermentation,  and  especially  putre- 
faction of  the  proteids,  go  with  incomplete  oxidation,  and  if  the 
theories  of  various  foreign  investigators,  which  have  been  con- 
firmed and  extended  by  observers  in  this  country,  are  accepted, 
we  must  believe  that  in  such  conditions  the  work  of  the  heart  is 
notably  increased  through  a  contraction  of  the  peripheral  blood- 
vessels. 

Summary. — To  sum  up,  then,  disorders  of  the  digestive  or- 
gans, and  especially  the  imperfect  metabolism  which  results 
from  them,  are  capable  of  injuring  the  heart  in  at  least  two 
ways:  (i)  By  impairing  the  nutrition  of  the  muscular  tissues 
of  the  heart  itself  through  imperfect  digestion  and  assimila- 
tion of  the  food;  (2)  by  increasing  the  work  of  the  heart 
through  a  narrowing  of  the  peripheral  blood-vessels — also  by 
a  roughening  of  their  lining  membrane — as  a  result  of  the 


968  THE    GASTRO-INTESTINAL    CLINIC 

toxic  action  of  certain  products  of  incomplete  oxidation  of 
the  proteids,  and  perhaps  other  faulty  metabolic  processes. 
(See  Lecture  LXXXII.) 

Therapeutics  of  Secondary  Cardiac  Affections. — Degenera- 
tive myocardial  changes,  with  hypertrophy  often  at  first,  but 
later  usually  some  degree  of  dilatation,  are  the  forms  of  dis- 
ease which  are  most  likely  to  result  from  the  digestive  and  nu- 
tritional disorders  just  described.  Manifestly,  when  a  contrac- 
tion of  the  peripheral  vessels  has  played  a  large  part  in  causing 
the  trouble,  the  curative  measures  which  will  be  most  promis- 
ing are  the  mildest  forms  of  exercise  and  the  hydriatic  pro- 
cedures which  tend  to  dilate  the  capillaries,  rather  than  any 
medicinal  remedies  which  exert  a  contrary  effect,  valuable  as 
the  latter  are  in  more  serious  conditions  of  cardiac  dilatation 
with  an  extremely  low  blood  pressure.  The  Nauheim  method 
of  treatment  usually  suits  well  in  the  latter  cases,  as  is  fully 
explained  in  Lecture  LXXXIL  It  is  equally  obvious  that  the 
primary  faults  in  the  digestive  apparatus  need  to  be  first  of  all 
removed,  and  such  a  regimen  instituted  as  shall  prevent  their 
recurrence. 

DISEASES   OF  THE   KIDNEYS  AND   DIABETES 

These  have  been  much  studied  as  to  their  influence  on  di- 
gestion, but  with  contradictory  results.  In  early  or  mild  cases, 
there  may  be  a  normal,  increased,  or  diminished  proportion  of 
HCl,  but  in  severe  or  advanced  cases,  naturally,  there  is  a 
diminution.  Riegel,  however,  reports  having  frequently 
found  a  normal  amount  of  HCl  in  even  old  chronic  cases  of 
renal  disease. 

Influence  of  Bright's  and  Diabetes  on  Digestion. — My  own 
experience  has  shown  a  like  variability  in  results  as  to  both 
Bright's  disease  and  diabetes,  except  that  diabetes  is  often  de- 
pendent on  disease  of  that  most  important  of  the  digestive 
glands,  the  pancreas.  There  is  no  constant  relation  between 
the  gastric  secretion  and  the  amount  of  albumin  or  sugar 
passed,  but  in  the  later  stages,  when  the  general  health  has 


RELATION    OF   GASTRO-INTESTINAL    TO    OTHER   DISEASES         969 

become  seriously  damaged,  gastric  secretion  suffeFs,  as  does 
'doubtless  that  of  all  the  glands. 

In  all  such  cases  it  is  important,  therefore,  to  make  tests  oc- 
casionally of  the  gastric  contents,  since  both  medicines  and  the 
diet  prove  most  effective  when  suited  to  the  condition  of  the 
stomach.  Persisting  long  with  alkaline  treatment  in  full  doses 
when  there  is  no  free  HCl,  cannot  help  but  destroy  what  little 
digestion  is  left,  and  on  the  other  hand,  administering  mineral 
acids  with  a  diet  rich  in  soups  and  meats,  or  meat  extracts  in 
any  form,  would  soon  play  havoc  with  a  case  of  diabetes  com- 
plicated with  hyperchlorhydria. 

As  in  the  case  of  the  heart,  disease  of  the  kidneys  may  ulti- 
mately result  from  certain  of  the  products  of  indigestion  and 
the  consequent  deranged  metabolism. 

In  a  medical  paper  written  by  me  ^  concerning  autotoxic 
forms  of  nephritis,  eighteen  cases  were  reported  showing  al- 
bumin and  casts  which  had  developed  apparently  as  a  result  of 
digestive  disorders.  All  but  one  were  cured,  or  markedly 
benefited,  by  a  persistent  employment  of  the  static  wave  and 
static  induced  currents. 

1  The  Effects  of  the  Secondary  Static  Currents  in  Removing  Albumin 
and  Casts  from  the  Urine,  with  Reports  of  Cases,  A7n.  Med.,  vol.  vi. 
No.  22. 


LECTURE  LXXXII 

ARTERIOSCLEROSIS  AND  ITS  RELATIONS 

TO    THE    AFFECTIONS    OF    THE 

GASTRO-INTESTINAL  TRACT 

The  relations  of  arteriosclerosis  with  gastro-intestinal  affec- 
tions are  reciprocally  so  intimate  and  so  exceedingly  important 
that  it  has  been  decided  to  discuss  them  somewhat  fully  and  at 
length  in  this  new  lecture  which  is  now  added  to  the  third 
edition  of  this  volume. 

A  study  of  the  literature  which  has  appeared  on  arterio- 
sclerosis during  the  last  two  decades,  forcibly  impresses  one 
with  the  increasing  appreciation  of  its  great  importance. 
Directly  or  indirectly,  it  probably  causes  a  majority  of  all 
deaths  in  adults.  Recent  investigations  indicate  that  not  only 
are  both  the  arteries  and  arterioles  more  or  less  generally  in- 
volved sooner  or  later,  in  the  inflammatory  and  degenerative 
processes  commonly  grouped  under  this  name,  but  also  in  many 
cases  the  veins,  venules,  and  capillaries,  so  that  the  term  angio- 
sclerosis  more  nearly  expresses  the  actual  pathologic  condition. 
The  disease  is  easily  diagnosed  by  even  a  tyro  in  medicine, 
when  far  advanced  and  hopeless.  To  recognize  it  in  its  in- 
cipiency,  when  a  cure  is  often  practicable,  is  very  difficult  and 
the  diagnosis  then  is  doubtless  rarely  made. 

The  symptoms  of  fully-established  arteriosclerosis  are  fa- 
miliar to  most  physicians,  and  those  of  the  advanced  stages, 
such  as  the  arcus  senilis,  thickened,  hardened,  and  tortuous 
surface  arteries,  apoplectic  or  apoplectiform  attacks  and 
paralyses,  as  well  as  dropsies  and  uremic  convulsions,  when 
the  kidneys  have  become  seriously  involved,  are  known  even  to 
many  of  the  laity.    The  earlier,  and  especially  the  premonitory, 

970 


ARTERIOSCLEROSIS    AND    GASTRO-INTESTINAL   AFFECTIONS      9/1 

symptoms  are  by  no  means  so  well  known.  They  are  fre- 
quently overlooked  or  neglected  in  spite  of  the  fact  that  their 
prom.pt  recognition  and  persistent  energetic  treatment  mean 
the  saving  of  lives  that  must  otherwise  be  wrecked — allowed  to 
drift  helplessly  on  to  the  rocks  of  apoplexy,  Bright's  disease, 
heart  failure,  etc.,  with  a  resulting  early  death,  or  what  is 
worse,  a  useless  prolongation  of  life  after  all  capacity  for 
serviceable  or  pleasurable  activity  has  been  lost. 

Among  the  earliest  symptoms  which  signify  that  the  ar- 
terial walls  are  being  irritated  and  their  integrity  endangered 
by  some  toxic  agent,  whether  it  be  a  poison  from  the  outside 
as  in  the  case  of  syphilis,  lead,  and  tobacco,  or  one  from  within 
(endogenous)  as  in  gout,  lithemia,  or  a  chronic  autotoxemia 
of  any  kind,  must  be  mentioned  especially  as  the  most  im- 
portant of  all,  increased  tension  in  the  arteries  with  augmented 
blood  pressure  as  revealed  by  the  sphygmomanometer  and 
much  less  certainly  by  the  finger  on  the  pulse.  By  this  valu- 
able instrument  of  precision,  which  every  family  physician 
should  now  possess  and  use  as  regularly  on  occasion  as  his 
clinical  thermometer  or  specula,  increased  blood  pressure  can 
be  certainly  detected  in  a  few  minutes  in  any  patient,  while  all 
the  other  early  symptoms,  except  the  findings  in  an  examina- 
tion of  the  eyeground,  are  likely  at  times  to  elude  or  mislead  us. 
Yet,  while  (apart  from  the  changes  in  the  eyeground)  no  other 
single  symptom  of  threatened,  or  actually  existing,  arterial 
disease  is  so  generally  present  up  to  the  time  when  the  heart 
has  yielded  to  the  overstrain  and  become  unequal  to  its  task, 
it  has  been  apparently  established  that  cases  of  arteriosclerosis 
do  occur  and  run  their  course  to  the  inevitable  fatal  termina- 
tion with  the  blood  pressure  always  subnormal.  Therefore, 
the  common  mistake  of  failing  to  recognize  the  disease  because 
the  blood  pressure  remains  low,  should  never  be  made.  As 
will  be  shown  later  on,  it  is  likely  that  the  pressure  in  many 
of  these  cases  might  be  found  to  be  abnormally  high  early  in 
the  morning  immediately  after  arising  from  bed,  especially 
after  eating  imprudently  the  previous  day.    My  observations  of 


972  THE    GASTRO-IXTESTINAL    CLINIC 

numerous  early  cases  have  generally  shown  a  pressure  ten  to 
thirty  points  higher  just  after  arising  than  in  the  afternoon,  or 
even  in  the  late  forenoon.  The  normal  systolic  pressure  in 
men  is  120  to  140,  according  to  age,  and  in  women,  no  to 
130  mm.  of  mercury. 

Dr.  A.  L.  Macleish  ^  of  Los  Angeles  has  emphasized  the 
importance  of  an  ophthalmological  examination  of  the  eye- 
ground  in  every  case  of  suspected  arteriosclerosis,  reminding 
us  that  the  disease  can  usually  be  thus  detected  long  before 
signs  of  it  are  apparent  elsewhere. 

Another  significant  symptom  which  can  often  be  seen  early 
is  a  pallor  of  the  skin  not  due  to  a  true  anemia,  the  blood 
count  being  at  or  near  the  normal  figures.  This,  being  a  result 
of  a  spasmodic  contraction,  of  the  vessels,  would  generally  be 
confirmed  by  finding  at  the  same  time  an  abnormally  high 
blood  pressure  and  swollen  vessels  in  the  retina. 

Other  symptoms  to  be  noted  in  a  later  stage  are  often 
vertigo,  tinnitus  aurium,  impaired  memory  and  sleep,  and 
mental  depression  and  also  intermittent  claudication;  failing 
nutrition  with  loss  of  weight,  and  unusual  proneness  to  infec- 
tions and  to  attacks  of  gastric  and  intestinal  indigestion;  but 
it  is  cjuestionable  whether  these  last  are  not  rather  the  results 
of  nutritional  and  metabolic  faults,  which  are  themselves  the 
real  causes  of  the  arterial  disease.  This  leads  us  to  the  con- 
sideration of  a  special  form  of  the  disease,  which  has  only 
within  the  last  few  years  been  receiving  much  attention,  viz : 

Arteriosclerosis   of   the   Abdominal   Vessels Stengel  ^   of 

Philadelphia  in  1904  referred  to  cases  of  an  intestinal  form 
of  arteriosclerosis  studied  by  him  in  hospital,  and  considered 
that  the  intractable  cases  of  chronic  colitis  so  often  encoun- 
tered are  probably  thus  explained. 

The  early  symptoms  of  this  form  seem  not  to  be  dis- 
tinguishable from  the  familiar  ones  of  indigestion  and  chronic 

^So.  Calif.  Prac,  January,  1907. 

2 "The  Clinical  Course  and  Diagnosis  of  Arteriosclerosis,"  Wis.  M-ed. 
four.,  vol.  iii,  No.  3,  1904. 


ARTERIOSCLEROSIS    AND    GASTRO-INTESTINAL   AFFECTIONS      973 

catarrh,  but  Buch  ^  mentions  repeated  severe  attacks  of  pain 
resembling  gastralgia  felt  near  the  navel  as  characteristic  of 
it.  They  may  recur  several  times  a  day  and  last  usually  a  few 
minutes  only,  seldom  half  an  hour  or  more.  They  may  be  pro- 
voked by  any  muscular  effort  as  walking  upstairs,  by  a  purga- 
tion, or  by  mental  strain — sometimes  merely  by  lying  down — 
and  though  usually  they  appear  to  have  no  relation  to  food  or 
eating,  they  seem  sometimes  to  be  superinduced  by  an  extra- 
heavy  meal.  Buch  maintains  very  positively  that  the  diagnosis 
may  be  made  by  a  therapeutic  test;  the  administration  of  three 
or  four  grams  daily  of  diuretin  or  five  to  eight  drops  of  the 
tincture  of  strophanthus  three  times  a  day,  he  says,  will  stop 
the  attacks  within  two  or  three  days  or  at  least  greatly  dimin- 
ish them,  and  sometimes  the  first  day,  if  they  are  due  to 
arteriosclerosis,  but  be  otherwise  without  effect. 

The  same  observer  found  the  aortic  second  sound  accentu- 
ated in  every  one  of  his  cases  and  also  the  abdominal  aorta, 
sensitive  on  pressure.  The  latter  symptom,  however,  I  have 
observed  in  a  great  variety  of  digestive  troubles  even  in  young 
dyspeptics  in  whom  there  was  no  suspicion  of  fault  in  the 
arteries.  Buch  describes  two  distinct  forms  of  pain  which  he 
ascribes  to  abdominal  arteriosclerosis,  ( i )  one  in  which  there 
is  no  involvement  of  the  thoracic  organs  in  the  painful  attacks, 
although,  when  the  heart  is  also  at  fault,  there  may  be  anginal 
pain  in  that  region  at  other  times;  and  (2)  a  form  in  which 
the  pain  may  begin  in  the  epigastrium  and  then  extend  to  the 
heart,  producing  there  a  true  stenocardial  attack,  or  z'ice  versa, 
the  pain  beginning  in  the  cardiac  region  and  extending  to  the 
abdomen.  More  recently  Mueller  -  of  Buda-Pest  has  reported 
the  results  of  an  elaborate  study  of  abdominal  arteriosclerosis, 
in  which  he  confirms  most  of  Buch's  previous  findings.  He 
quotes  Hasenfeld  as  having  proved  by  histological  researches 
that  arteriosclerosis  of  the  abdominal  viscera  is  not  only  much 
more  frequent  than  generally  supposed,  but  is  also  the  chief 

1  Sf.  Petersburgh  Med.    Woch.,  No.  27,  1904. 

^  Allg.  IVzetier  Med.  Zeitung,  Nos.  37  to  40,  1909. 


974  THE    GASTRO-INTESTINAL    CLINIC 

cause  of  cardiac  h3qDertrophy,  and  cites  Kuemmel  as  holding, 
as  a  result  of  extensive  in^'estigations,  that  sclerosis  of  the 
abdominal  vessels  is  very  common.  He  also  reports  communi- 
cations from  various  other  writers  concerning  ulceration  and 
thrombosis  in  the  gastro-intestinal  tract  leading  to  fatal  hemor- 
rhage in  some  of  the  cases.  Mueller  explains  the  sclerotic 
pains  of  the  abdomen  as  a  neuralgia  of  the  lumbar  sympathetic 
and  believes  that  very  many  of  the  ailments  commonly  classed 
as  neuroses  of  the  stomach  and  intestines  are  really  results  of 
arteriosclerosis  of  the  gastro-intestinal  tract. 

.Etiology. — Daland  ^  of  Philadelphia  holds  that  in  this  coun- 
try the  order  of  frequency  of  the  causes  of  arteriosclerosis  is 
as  follows :  (i)  excessive  muscular  work;  (2)  alcoholism;  (3) 
syphilis;  (4)  excess  in  food,  especially  of  the  nitrogenous 
variety;  (5)  gout;  (6)  intestinal  toxemia;  (7)  uremia;  (8) 
excessive  mental  work,  especially  in  those  possessing  a  neurotic 
temperament;  (9)  various  infections  such  as  rheumatism, 
chronic  septicemia,  typhoid  fever,  etc.;  (10)  plumbism;  (11) 
nicotinism;  (12)  long-continued  excess  in  fluids;  (13)  con- 
genitally  weak  vascular  apparatus,  (a)  syphilis,  (b)  offspring 
of  senile  parent  or  parents,  (c)  unknown  causes. 

This  is  the  most  complete  list  of  such  causes  that  I  have 
seen;  yet  my  own  observations  indicate  that  there  are  prob- 
ably still  a  few  others,  which  shall  be  mentioned  later.  They 
also  suggest  some  question  as  to  the  order  of  frequency.  While 
the  records  of  the  hospitals  and  clinics  from  which  most  of  our 
published  statistics  are  drawn,  would  doubtless  warrant  the 
placing  of  muscular  strain,  alcohol,  and  syphilis  very  high  up 
in  the  list  of  causes,  since  such  statistics  deal  with  a  class  of 
patients  in  whom  these  are  prevalent  far  above  the  average, 
there  can  be  little  doubt  that  among  private  patients,  even  in 
cities  and  especially  among  the  people  generally  who  live  out- 
side of  the  large  cities,  the  three  setiologic  factors  named  belong 
lower  down  on  the  list  in  the  order  of  frequency;  also  that, 
among  the  well-to-do  classes  at  least,  the  various  forms  of 
^Monthly  Cyclopedia  of  Pract.  Medicine,  vol.  x.  p.  145,  1907. 


ARTERIOSCLEROSIS    AND    GASTRO-INTESTINAL   AFFECTIONS      975 

autotoxemia  resulting  from  high  Hving — overeating  or  over- 
burdening the  digestive  and  ehminating  organs  with  both 
food  and  drink,  particularly  alimentation  out  of  proportion  to 
oxygenation — demand  first  place. 

The  role  of  alcohol  in  this  connection  calls  for  special  men- 
tion. Probably  a  majority  of  both  American  and  foreign 
authors  agree  with  Daland  in  considering  it  one  of  the  most 
frequent  causes  of  arteriosclerosis,  but  Cabot  of  Boston  has 
reported  that  a  study  of  the  inmates  of  a  large  hospital  for 
inebriates  showed  only  6  per  cent,  affected  with  arteriosclerosis 
— less  than  the  average  among  adults  generally.  Clifford  All- 
butt  has  suggested  that  probably  alcoholic  beverages  have  been 
an  astiologic  factor  chiefly  by  conducing  to  overeating,  which 
all  now  concede  to  be  one  of  the  principal  causes  of  arterial 
disease.  At  all  events,  the  beers  and  wines  that  are  so  largely 
drunk  abroad,  tend  more  to  produce  fermentation  and  flatu- 
lency which,  according  to  my  experience,  increase  blood  pres- 
sure, while  the  spirits  predominantly  consumed  in  this  country, 
especially  by  most  heavy  drinkers  and  hospital  inmates,  actu- 
ally lower  the  blood  pressure,  pernicious  as  is  their  effect  other- 
wise on  the  liver,  nerve  tisues,  etc. 

A  recent  exhaustive  paper  by  Pottenger  of  Los  Angeles  con- 
cerning the  effects  of  tuberculosis  on  the  circulation  proves 
that  this,  the  most  widespread  of  all  infections,  like  various 
other  ones,  can  set  up  gradually  the  lesions  of  arteriosclerosis. 
The  cases  studied  particularly  numbered  162.  Of  28  patients 
who  had  been  ill  less  than  a  year,  one-half  had  thickened  radial 
arteries;  in  41  ill  between  one  and  two  years,  20  had  the  same; 
while  in  93  ill  over  two  years,  60,  or  nearly  two-thirds,  had 
palpably  thickened  radials.  The  blood  pressure  was  constantly 
subnormal  in  all,  thus  revealing  one  condition  capable  of  caus- 
ing those  cases  of  arteriosclerosis  in  which  the  blood  pressure 
remains  always  low. 

Puerperal  fever  is  another  of  the  acute  infections  which 
have  been  shown  to  be  capable  of  causing  arteriosclerosis. 

Pathology. — Viewing  the  disease  for  our  purposes  here  in 


9/6  THE    GASTRO-INTESTINAL    CLINIC 

its  practical  relations  chiefly,  with  regard  to  its  prevention  and 
its  possible  cure  in  the  earlier  stages,  as  well  as  retarding  its 
fatal  course  in  later  stages,  the  patliology  of  arteriosclerosis 
need  be  only  broadly  and  briefly  discussed.  The  vessels  be- 
come very  gradually  altered  so  that  their  walls  are  thicker  and 
stiffer,  their  lumen  lessened  and  their  lining  membrane  rough- 
ened, while  the  blood  generally  has  an  increased  viscosity. 
Local  dilatations  follow  in  the  arteries,  as  well  as  in  the  heart 
itself;  aneurisms  may  result  even  in  the  smallest  vessels,  w4tli 
later  rupture  and  hemorrhage  often  lethal,-  especially  when  in 
the  brain.  In  a  large  proportion  of  cases  the  renal  vessels  are 
eventually — sometimes  early — involved  with  the  development 
of  Bright' s  disease.  The  vessels  which  supply  the  digestive 
organs  including  the  pancreas  (less  frequently  the  liver),  the 
stomach,  and  intestines  are  now  known  to  be  often  primarily 
affected — perhaps  in  all  the  very  large  proportion  of  cases  in 
which  dietetic  faults  have  been  the  cause — and  in  any  case  be- 
come ultimately  and  increasingly  involved  so  that  the  digestive 
secretions  diminish  and  the  glands  and  muscles  both  atrophy 
until  finally,  even  when  ruptures  of  vessels  or  other  more  seri- 
ous accidents  have  been  escaped,  death  results  from  marasmus 
or  toxemia  through  failure  of  the  kidneys,  liver,  etc.,  to  clear 
the  system. 

The  exact  nature  of  the  earlier  changes  in  the  vessels — the 
minuter  histology  of  the  morbid  processes — is  of  far  less  im- 
portance, to  express  Allbutt's  opinion  in  different  phrase,  than 
the  causes,  the  results,  and  the  means  by  which  they  can  be 
prevented,  stopped,  or  at  least  retarded. 

Diagnosis. — Continued  high  blood  pressure  in  a  person  under 
forty,  or  in  any  except  the  very  old,  would  alone  warrant  the 
diagnosis  of  either  existing  or  threatened  presenile  arterio- 
sclerosis. When  found  together  with  superficial  vessels  visibly 
or  palpably  thickened  the  condition  cannot  well  be  referred  to 
anything  else  except  physiologic  or  senile  arteriosclerosis.  In 
the  form  of  the  disease  which  runs  its  course  without  ever 
showing  an  excessive  blood  pressure,  and  in  the  later  stages 


ARTERIOSCLEROSIS    AND   GASTRO-INTESTINAL   AFFECTIONS      977 

of  the  more  usual  fonn,  after  cardiac  insufficiency  and  low 
blood  pressure  have  resulted,  the  diagnosis  must  rest  upon  the 
thickened  condition  of  the  superficial  vessels  discoverable  by 
the  unaided  eye  and  touch,  and  especially  by  an  ophthal- 
mologic examination  of  the  eyeground.  The  mental,  nervous, 
and  renal  symptoms  usually  also  present,  make  up  a  picture 
which  is  unmistakable  for  even  cases  in  only  a  moderately 
advanced  stage.  In  the  earlier  stages  the  condition  of  the 
blood  pressure  and  the  ophthalmologic  findings  often  afford  the 
only  reliable  means  of  deciding  and  when  the  increased  blood 
pressure  is  wanting  the  latter  findings  may  be  the  only  depend- 
ence. As  Macleish  forcibly  puts  it,  "  a  man  is  as  old  as  his 
arteries;  how  old  his  arteries  are,  the  ophthalmologist  is  in  a 
position  to  discover  before  brain  or  heart  or  even  kidney 
tells  the  tale."  ^  When  there  are  suspicions  of  a  combination 
of  tuberculosis  with  disease  in  the  arteries,  the  tuberculin 
test  and  eyeground  findings  must  join  in  helping  to  an  early 
diagnosis,  since  then  the  blood  pressure  is  usually  subnormal. 

It  is  important  to  distinguish  secondary  from  primary  low 
blood  pressure.  The  former  has  always  been  preceded  by  a 
period  of  high  pressure  at  a  time  when  there  should  have  been 
comparative  vigor  accompanied  by  the  symptoms  of  hyper- 
tension, a  history  which  careful  inquiry  should  be  able  to 
elicit. 

Clinical  Observations  on  Blood  Pressure  by  the  Author — 
A  summary  of  observations  carried  out  in  part  with  the  as- 
sistance of  Dr.  F.  E.  Corey  at  his.  Sanatorium  in  Alhambra, 
Cal.,  will  appropriately  precede  here  a  discussion  of  the 
treatment.  Besides  routine  examinations  in  a  large  number  of 
other  case's,  there  were  made  on  four  persons  who  volunteered 
for  the  purpose,  several  hundred  obser\^ations  of  the  systolic 
blood  pressure  by  means  of  the  Riva  Rocci  sphygmomanometer, 
before  and  after  exercises  of  various  kinds  and  degrees  of 
activity,  before  and  after  meals,  and  different  forms  of  hydri- 
atic  procedures,  electric  treatments,  etc. ;  also  at  various  hours 

"^Loc.  cit. 


gyS  THE    GASTRO-INTESTINAL    CLINIC 

of  the  day  and  night,  especially  on  retiring  and  on  arising 
after  a  night's  sleep.  One  of  the  four  was  a  professional  man 
68  years  old,  who  had  had  somewhat  atonic  gastro-intestinal 
viscera  and  moderate  arteriosclerosis  for  over  ten  years  with 
always,  for  years,  a  high  pressure  in  the  morning.  Another 
of  them  was  a  lady  aged  65  who,  though  possessed  of  a  first- 
class  digestion,  showed  signs  of  beginning  arteriosclerosis 
with  high  pressure,  especially  in  the  early  morning.  The  third, 
a  merchant  aged  29,  had  a  low  arterial  tension  and  various 
nervous  symptoms,  due  probably,  in  part  at  least,  to  tobacco. 
The  fourth  was  a  lady  of  23,  in  whom  a  tuberculous  infiltration 
of  one  lung  had  been  arrested  by  the  tuberculin  treatment. 
Her  blood  pressure  and  pulse  rate  were  variable. 

The  results  of  these  observations  may  be  briefly  summarized 
as  follows : 

I.  Exercise  of  all  kinds,  from  the  gentlest  to  the  most 
active  and  vigorous,  is  followed,  after  a  brief  rise  of  blood 
pressure  and  increase  in  the  pulse  rate  (which  can  be  made 
very  slight  and  transient),  by  a  decided  fall  of  from  5  to  50 
mm.  of  mercury,  according  to  the  severity  and  duration  of  the 
exercise  and  the  condition  of  the  patient.  Generally  the  pulse 
rate  increases  as  the  pressure  falls,  but  the  gentler  exercises, 
especially  those  against  resistance  (Widerstandgyninastik)  car- 
ried out  in  accordance  with  the  rules  of  the  Schott  brothers  of 
Nauheim,  will  leave  the  pulse  rate  unchanged,  or  when  very 
rapid  before,^  slowed  and  strengthened.  As  a  rule,  the  higher 
the  pressure  before,  the  greater  is  the  fall  after,  the  exer- 
cise. It  is  possible  that  cases  complicated  by  serious  renal 
disease  may  prove  exceptions  in  this  respect,  but  I  have 
not  had  an  opportunity  of  testing  such  a  case  thoroughly. 
The  elaborate  Schott  rules  are  not  necessary  to  obtain  very 
favorable  results,  except  in  the  weakest  patients.  Ten  to 
twenty  minutes  spent  in  making  a  variety  of  muscular  move- 
ments, not  more  than  two  to  ten  or  twenty  of  each  kind,  the 
number  depending  upon  the  degree  of  the  cardiac  tone  (the 
weaker  the  heart  the  fewer  and  the  more  slowly  to  be  made). 


ARTERIOSCLEROSIS   AND   GASTRO-INTESTINAL  AFFECTIONS      979 

will  nearly  always  produce  decided  results.  An  attendant  is 
not  necessary  after  the  patient  has  been  taught  to  resist  him- 
self by  contracting  moderately  the  muscle  opposed  to  the  one 
in  action.  Pulleys  also  can  be  adapted  so  as  to  give  the  proper 
amount  of  resistance,  but  the  patient  needs  to  be  cautioned 
always  not  to  overexert  in  any  of  these  ways.  The  gentlest 
exercises  do  the  most  good  in  feeble  patients. 

2.  Mental  exertion  has  produced  varying  results,  but  never 
in  my  experience  a  lowering  effect  on  the  blood  pressure  unless 
after  exhaustion.  When  very  severe  or  exciting  it  tends  to 
raise  the  pressure,  but  otherwise  is  likely  to  leave  it  unchanged. 

3.  During  the  period  of  digestion,  from  one  to  three  hours 
after  a  simple  ordinary  meal,  not  including  tea,  coffee,  or 
alcoholics,  I  have  found  the  blood  pressure  usually  lowered, 
often  decidedly,  though  it  has  sometimes  been  transiently 
raised  before  falling,  as  happens  with  exercise.  Whenever, 
however,  a  flatulent  distention  of  the  intestines  has  resulted, 
as  especially  during  the  night  in  dyspeptics,  the  pressure  has 
been  raised.  The  pulse  rate  has  been  always  higher  after 
meals. 

4.  The  cumulative  effect  of  any  special  diet  is  a  different 
matter.  An  exclusive  milk  or  meat  diet  has  generally  lowered 
the  pressure  in  arteriosclerotics  when  previously  high, — in  one 
of  my  cases,  markedly, — but  the  ultimate  effect  of  the  meat 
diet  has  been  aggravation  of  the  disease  in  the  vessels  as  shown 
by  the  nervous  and  other  serious  symptoms.  Thus  the  almost 
universal  advice  of  writers  that  these  patients  should  eat  meat 
very  sparingly,  if  at  all,  is  justified  by  my  observations. 

5.  In  the  great  majority  of  my  observations,  as  before  men- 
tioned, the  blood  pressure  has  been  found  very  much  higher 
shortly  after  rising  than  later  in  the  day,  especially  in  patients 
not  confined  to  bed.  This  rise  has  been  particularly  marked 
in  patients  troubled  with  "flatulence,  but  by  no  means  confined 
to  them.  Various  causes  probably  contribute  to  this  result. 
The  reflex  stimulation  of  the  heart  by  the  distention  is  pos- 
sibly one;  the  absence  of  the  pressure-lowering  influence  of 


980  THE    GASTRO-INTESTINAL    CLINIC 

digestion  and  the  other  activities  of  the  day  and  evening  is 
probably  another,  and  the  tonic  effect  of  prolonged  rest  and 
sleep  upon  the  heart  must  also  be  a  factor. 

No  other  observer  seems  to  have  noted  this  usually  marked 
difference  between  the  evening  and  morning  blood  pressures, 
and  it  is  always  to  be  borne  in  mind  in  managing  important 
cases  of  arteriosclerosis. 

The  particular  directions  for  the  treatment  of  arteriosclerosis 
were  very  fully  given  in  the  paper  presented  by  me  to  the 
American  Climatological  Association,  at  its  meeting  at  Old 
Point  Comfort  in  1909,  and  they  are  reproduced  here  in  part 
with  such  changes  and  additions  as  newer  developments  have 
suggested. 

Prophylaxis  and  Treatment — The  prophylaxis  of  arterio- 
sclerosis demands  the  avoidance  of  the  causal  conditions  al- 
ready mentioned  or  the  removal  of  them,  in  so  far  as  is  possible, 
when  they  are  already  in  existence.  To  prevent  a  premature 
hardening  of  the  arteries  with  its  usual  consequences,  one 
needs  to  have,  first,  a  good  inheritance,  and  then  to  live  hy- 
gienically  in  all  ways — to  be  temperate  in  eating  and  drinking 
especially,  but  also  in  everything.  And  the  more  strenuous  the 
life  in  regard  to  the  mental  and  emotional  activities,  in  par- 
ticular, the  greater  the  importance  of  not  overtaxing  the  diges- 
tive system.  Then,  after  middle  age,  if  not  before,  one  should 
be  examined  at  least  once  a  year,  as  to  the  blood  pressure  and 
condition  of  the  kidneys  especially,  if  not  a  more  general  ex- 
amination, so  as  to  combat  any  signs  of  the  trouble  in  its 
incipiency. 

The  treatment  will  need  to  vary  with  the  nature  of  the  cause. 
The  cases  due  to  poisons  coming  from  outside  the  body  de- 
mand especially  medicinal  antidotes  and  eliminants — in  par- 
ticular the  iodides  for  syphilis  and  lead.  Those  dependent 
upon  physical,  mental,  or  emotional  overstrain  may  require 
more  complete  rest  from  the  offending  cause — from  the  par- 
ticular form  of  over-activity — sometimes  even  a  rest  cure  in 
bed,   but  otherwise  much   the   same   treatment  as  the  more 


ARTERIOSCLEROSIS   AND   GASTRO-INTESTINAL  AFFECTIONS      98 1 

prevalent  autotoxic  cases,  except  that  the  diet  may  not  need  to 
be  so  much  restricted.  For  the  remaining  cases  due  mainly 
to  autotoxemia  and  comprising  the  great  bulk  of  all  the  cases 
of  arteriosclerosis,  the  treatment  must  depend  upon  the  stage 
of  the  affection. 

The  stage  in  which  the  disease  is  usually  first  recognized  is 
that  of  cardiac  hypertrophy,  when  the  blood  pressure  is  per- 
sistently high  as  a  rule,  though  often  easily  and  rapidly  lowered 
by  even  gentle  exercise,  fasting,  or  low  diet,  the  nitrites,  car- 
diac depressants,  tepid  or  warm  baths,  bleeding  or  particularly 
by  prolonged  active  exercise  but,  as  a  rule,  not  carried  to  the 
point  of  fatigue. 

Finally,  we  have  the  stage  of  broken  compensation  with  gen- 
erally low  blood  pressure,  the  heart  having  yielded  to  the  pro- 
longed overstrain,  so  that  unaided  it  is  no  longer  equal  to  the 
task  of  forcing  a  sufficient  supply  of  blood  through  the  ob- 
structed vessels. 

The  general  principles  to  be  kept  ever  in  mind  and  made 
the  dominant  features  of  the  treatment  are  these  two : 

1.  To  spare  in  every  way  possible  the  vital  organs  involved, 
i.e.,  the  circulatory,  digestive,  and  eliminating  organs,  espe- 
cially the  heart  and  kidneys. 

2.  To  assist  any  of  these  organs  found  to  be  flagging  in  their 
indispensable  work. 

When  they  flag  or  begin  to  fail,  the  important  principle  of 
sparing  them,  in  so  far  as  practicable,  rather  than  urging  them 
harder,  should  never  be  overlooked.  Before  bringing  to  bear 
our  stimulant  remedies — our  whips  and  spurs — we  should  try 
to  lessen  their  work — relieve  them  of  part  of  the  burden.  E.g., 
we  can  and  should  spare  all  the  organs  concerned  by  keeping 
the  total  amount  of  the  ingesta  of  all  kinds  strictly  within  the 
needs  of  the  system,  and  also  by  avoichng  or  restricting  the 
quantity  of  those  kinds  of  food  and  drink  which  either  unduly 
tax  the  digestive  and  eliminating  functions.  Or  introduce  poi- 
sons from  without  which  the  excretory  organs  must  then  cast 
out,   in   addition  to   excreting   the   toxic   matters   constantly 


982  THE    GASTRO-INTESTINAL    CLINIC 

formed  within  the  body.  When,  notwithstanding  the  utmost 
care  of  the  diet,  the  kidneys  show  signs  of  being  unequal  to 
their  task,  we  should  call  upon  the  bowels  to  do  more,  and, 
above  all,  compel  that  great,  but  often  neglected,  emunctory,. 
the  skin,  to  do  better  work  by  prescribing  some  of  the  many 
procedures,  or  drugs,  which  will  increase  the  perspiration. 

When  the  heart  begins  to  be  embarrassed  and  all  unneces- 
sary demands  upon  it  have  been  stopped  by  lessening  the 
amount  of  the  ingesta  to  within  the  quantities  actually  required 
to  maintain  nutrition,  and  by  placing  the  patient  at  either  com- 
plete or  partial  rest,  much  more  can  still  be  done  in  the  way  of 
relieving  it.  We  can  widen  the  blood  paths  by  means  of  the 
various  practicable  mechanical  measures  for  increasing  the 
activity  of  the  peripheral  circulation,  as  well  as  by  the  adminis- 
tration of  drugs  which  tend  to  dilate  the  vessels.  Failing  these 
remedies,  or  in  urgent  cases,  simultaneously  with  them,  drugs 
of  the  digitalis  group  may  need  to  be  also  administered. 

When  indigestion  is  a  feature  of  the  case,  a  careful  diagnosis 
should  be  made  of  the  exact  fault  and  the  proper  remedy  then 
be  applied. 

1.  Should  we  be  fortunate  enough  to  recognize  an  incipient 
case  of  arteriosclerosis,  of  the  prevalent  autotoxic  type,  before 
the  heart  has  hypertrophied,  we  can  very  hopefully  apply  the 
principle  of  economizing  the  vital  forces.  We  have  only  as  a 
rule  to  prevent  overdoing,  overeating,  and  overdrinking — ^to 
regulate  the  patient's  diet  both  as  to  quantity  and  quality — 
to  correct  any  digestive  or  other  setiologic  fault  and  see  to  it 
that  the  eliminating  organs  do  their  full  duty  in  order  to  spare 
the  heart  and  arteries  further  embarrassment  and  effect  a  cure. 
In  this  stage,  constipation  will  very  often  be  found,  and,  before 
matters  have  progressed  too  far,  an  earnest  effort  to  cure  it 
radically  should  always  be  made,  by  means  of  a  laxative  diet, 
special  exercises,  etc.  (See  Lecture  LXX.)  But  complete 
daily  bowel  movements  must  be  secured  even  with  laxative 
drugs,  if  not  obtainable  otherwise. 

2.  In  the  stage  of  cardiac  hypertrophy  the  same  things  need 


ARTERIOSCLEROSIS    AND   GASTRO-INTESTINAL   AFFECTIONS      983 

to  be  done  still  more  thoroughly  and  perseveringly,  and,  be- 
sides, whatever  further  is  required  to  keep  the  blood  pressure 
within  the  limits  normal  for  the  patient's  age,  say  from  120  to 
140  or  150  Hg.  We  must  then  secure  for  the  patient  as  much 
physical  and  mental  rest  as  is  necessary  and  practicable,  pre- 
scribe a  diet  appropriate  to  the  gastro-intestinal  findings,  with 
a  minimum  of  flesh  food  and  no  meat  extractives  or  stimulants, 
besides  ordering  massage  and  Swedish  movements,  or  other 
passive  exercises;  or,  in  the  milder  cases,  the  gentler  forms  of 
active  exercise.  If  need  be,  we  may  add  general  faradization 
or  d'Arsonvalization  (perhaps  now  the  most  effective  single 
remedy  for  high  tension)  and  spongings  with  hot  salt  water, 
or  even  short,  warm  tub  baths,  or  salt  rubs  followed  by 
prolonged  brisk  toweling;  in  short,  whatever  forms  of  baths 
or  local  treatment  will  best  keep  the  skin  active  and  lower  the 
blood  pressure,  without  weakening  the  heart.  If  these  meas- 
ures fail,  as  they  sometimes  will,  especially  when  the  kidneys 
are  involved,  we  must  push  drug  remedies,  such  as  the  nitrites, 
besides  purging  or  even  bleeding  in  serious  cases  in  which  the 
tension  remains  obstinately  high,  to  any  extent  necessary,  while 
at  the  same  time  keeping  the  heart  up  to  its  work  by  giving 
cardiac  tonics  cautiously,  if  required. 

3.  When  the  heart  has  dilated,  the  problem  is  more  com- 
plicated. Besides  the  sparing,  eliminating,  and  tonic  measures 
already  described,  the  saline  baths  of  Nauheim,  Germany,  and 
the  resisted  movements  first  introduced  by  the  Schott  brothers 
there,  may  be  resorted  to  hopefully  in  cases  not  too  far  ad- 
vanced. They  are,  of  course,  well  known  to  most  physicians. 
The  baths  in  the  natural,  carbonated,  saline  water,  together 
with  the  Widersfandgymnastik,  as  carried  out  by  the  trained 
attendants  there,  are  very  effective  in  appropriate  cases,  as  I 
can  personally  testify,  having  spent  a  season  there  once  with 
a  patient;  but  the  artificial,  carbonated  saline  baths  given  at 
some  of  the  sanatoria  in  this  country  as  a  substitute,  serve  the 
purpose  well  in  skillful  hands,  and  it  should  not  be  very  diffi- 
cult for  any  person  to  learn  in  a  short  time  how  to  assist  a 


984  THE    GASTRO-INTESTINAL    CLINIC 

patient  to  make  the  resisted  movements  with  the  requisite  care 
and  skill.  In  the  severer  cases,  however,  it  will  often  be  neces- 
sary to  push  boldly  some  active  cardiac  tonic  in  addition  to  the 
mechanical  measures  mentioned. 

In  prescribing  the  diet  only  a  few  general  rules  can  be  laid 
down,  since  so  much  depends  upon  the  condition  of  the  diges- 
tiv*e  organs.  When  there  is  dilatation  or  marked  atony  of  the 
stomach  or  intestines,  large  amounts  of  licjuid  disagree  and  are 
therefore  doubly  contra-indicated.  In  these  cases  the  carbohy- 
drates need  to  be  as  much  restricted  as  practicable,  since  they 
are  very  prone  to  ferment  and  produce  flatulence,  which,  as  my 
experience  shows,  raises  the  blood  pressure  and  generally  im- 
pairs the  sleep. 

When  there  is  hyperchlorhydria,  the  metabolism  will  be  so 
seriously  disordered  thereby,  that  little  progress  toward  an 
improvement  of  the  circulation  can  be  expected  until  this  com- 
plication (or  possibly  the  chief  causal  condition)  has  been 
removed  by  the  appropriate  diet  and  other  treatment.  When 
there  is  a  displacement  of  any  of  the  abdominal  viscera,  espe- 
cially of  the  stomach  and  kidneys,  little  can  usually  be  accom- 
plished until  the  fault  has  been  corrected.  So  with  gall- 
stones, chronic  pancreatitis,  and  all  the  other  manifold  dis- 
orders which  affect  the  gastro-intestinal  tract  and  are  believed 
to  play  a  prominent  part  in  the  aetiology  of  many  cases  of 
arteriosclerosis. 

The  majority  of  writers  hold  that  certain  kinds  of  food  and 
drink  and  so-called  food  accessories,  as,  e.g.  the  flesh  foods,  the 
alcoholic  beverages  and  other  stimulants,  particularly  tea  and 
coffee,  because  their  alkaloids  are  practically  identical  with 
some  of  the  toxic  purin  bases,  and  tobacco,  which  seems  to  be 
worst  of  all,  have  an  especially  injurious  effect  in  arterio- 
sclerosis. I  am  convinced  that  an  excessive  quantity  of  food 
and  drink  taken  regularly  day  after  day,  is  even  more  harm- 
ful in  this  respect  than  a  moderate  amount  of  some  one  or 
more  of  the  incriminated  articles  above  mentioned.  That  such 
an  excess  tends  to  produce  hypertention  is  certain,  and  pro- 


ARTERIOSCLEROSIS    AND   GASTRO-INTESTINAL  AFFECTIONS      985 

longed  hypertention  has  been  shown  to  be  a  very  prominent 
cause  of  arteriosclerosis. 

It  remains  to  speak  of  climatotherapy  in  arteriosclerosis. 
Climate  can  help  much  in  the  treatment.  Moderate  warmth 
and  dryness  promote  the  action  of  the  skin,  and  joined  with 
equability  afford  the  arteriosclerotic  the  most  favorable  exter- 
nal conditions  for  attaining  a  high  old  age  in  spite  of  his  dis- 
abilities. Many  places  in  our  great  Southwest  suit  well,  espe- 
cially for  the  winter  months. 

When  the  patient  can  live  all  the  year  round  in  such  a  com- 
paratively dry  and  equable  climate  as  that  of  Southern  Cali- 
fornia, at  nearly  the  sea  level,  his  chances  for  improvement 
will  be  greatly  increased.  This  is  especially  true  for  the  more 
favored  localities  of  that  region  near  the  coast.  The  blood 
pressure  is  not  disturbed  in  this  region  by  either  altitude  or 
violent  storms,  cold  waves  or  extreme  changes  of  temperature, 
such  as  prevail  so  much  of  the  time  in  many  parts  of  our 
country. 

For  patients  who  are  difficult  to  control  or  whose  environ- 
ment is  unfavorable  for  whatever  cause,  and  especially  for 
advanced  cases  with  secondary  low  arterial  tension,  in  which 
the  heart  unaided  is  no  longer  equal  to  the  task  of  maintain- 
ing the  circulation,  sanatorium  treatment  in  a  good  climate, 
with  sometimes  a  Weir  Mitchell  rest-cure,  offers  the  best  pos- 
sible remedy.  In  this  way  only  can  a  suitable  hygienic  and 
mechanical  treatment  by  diet,  massage,  resisted  movements, 
baths,  including  in  appropriate  cases  the  Nauheim  baths,  elec- 
tricity, etc.,  be  systematically  carried  out. 


LECTURE  LXXXIII 

THE   SURGERY   OF   THE    STOMACH 
AND    INTESTINES 

In  this  lecture  attention  is  called  to  some  of  the  leading 
indications  for  surgical  interference  in  a  certain  class  of 
gastro-intestinal  diseases.  No  attempt  will  be  made  to  de- 
scribe minutely  each  operation  and  the  technicjue  employed, 
but  since  the  general  practitioner  often  has  not  the  time  and 
opportunity  to  keep  fully  informed  concerning  all  the  advances 
in  surgery,  a  brief  outline  will  be  given  of  some  of  the  oper- 
ative methods  usually  adopted  by  the  best  surgeons. 

SURGERY   OF  THE   STOMACH 

Gastric  Ulcer. — A  great  many  ulcers  of  the  stomach  can  be 
cured  if  they  are  systematically  treated  by  means  of  rest,  diet, 
good  hygiene,  and  careful  medication.  It  is  a  mistake,  how- 
ever, to  persevere  too  long  with  palliative  measures,  and 
surgical  aid  should  always  be  sought  whenever  the  patient 
grows  gradually  worse  in  spite  of  treatment,  or  continues  to 
vomit  blood  and  ingesta.  Perforations,  chronic  indurated 
ulcers,  and  perigastric  adhesions  are  conditions  that  are  prac- 
tically never  cured  except  by  an  operation.  As  soon  as  a 
probable  diagnosis  of  a  perforation  is  established,  the  abdomen 
should  be  opened  and  careful  search  made  for  the  point  of 
rupture.  It  is  generally  quickly  found,  for  in  the  majority 
of  cases  it  is  located  on  the  anterior  wall  near  the  lesser  curva- 
ture and  is  easily  accessible.  A  perforation  on  the  posterior 
wall  should  be  approached  through  an  opening  in  the  trans- 
verse mesocolon;  this  opens  up  the  lesser  peritoneal  cavity 
and  gives  free  access  to  the  whole  posterior  surface  of  the 


THE    SURGERY    OF    THE    STOMACH    AND    INTESTINES       987 

stomach.  The  method  of  closing  the  perforation  depends  upon 
the  size  of  the  opening  and  the  condition  of  the  surrounding 
tissue.  If  it  is  small,  a  purse-string  suture  reenforced  by  a 
few  interrupted  Lambert  sutures  is  all  that  is  necessary.  The 
large  ragged  openings  should  be  treated  by  first  carefully 
excising  the  ulcerated  area,  and  then  uniting  the  freshened 
edges  with  a  double  layer  of  sutures.  Should  the  perforation 
happen  at  a  time  when  the  stomach  is  empty  and  there  is  not 
sufficient  leakage  to  soil  the  peritoneal  cavity,  it  is  possible 
to  close  the  abdomen  without  drainage,  but,  if  in  doubt,  it 
is  safer  to  make  a  stab  wound  above  the  pubis  and  insert 
a  rubber  drainage  tube  into  the  cul-de-sac  of  Douglas.  The 
reported  mortality  from  perforations  is  gradually  becoming 
less,  the  result  largely  of  an  increasing  number  of  operations 
done  early  and  before  the  onset  of  peritonitis. 

Perigastric  Adhesions — When  these  are  extensive  enough 
to  cause  serious  trouble  with  the  stomach  and  intestines,  the 
only  rational  treatment  is  to  open  the  abdomen  and  break 
them  up;  all  raw  spaces  should  be  covered  with  peritoneum 
and  omentum  so  as  to  prevent  the  adhesions  from  forming 
again.  Chronic  indurated  ulcers  of  the  stomach  and  all  those 
not  favorably  influenced  by  medical  treatment  demand  surgical 
interference.  The  operation  of  choice  is  a  gastro-jejunostomy, 
for  it  provides  the  affected  area  with  rest  and  good  drainage, 
which  are  the  two  essential  principles  in  effecting  a  cure.  It 
is  not  considered  necessary  in  all  cases  to  excise  the  ulcer 
at  the  time  of  the  operation  and  this  should  only  be  done  when 
it  is  situated  at  some  easily  accessible  point. 

Cicatricial  Stenosis  of  the  Cardiac  Opening  of  the  Stomach. 
— Spasmodic  strictures  and  organic  strictures  the  result  of 
traumatic,  chemical,  or  thermal  irritation  should  be  treated, 
when  possible,  by  passing  down  the  esophagus  from  time  to 
time  graduated  bougies,  but  if  this  cannot  be  accomplished, 
the  abdomen  must  be  opened,  the  stomach  incised,  and  an 
attempt  made  to  overcome  and  dilate  the  stricture  by  passing 
bougies  from  below  upward.     Strictures  which  result  from 


988  THE    GASTRO-INTESTINAL    CLINIC 

malignant  growths  and  all  those  not  benefited  by  the  bougie 
treatment  frequently  require  a  gastrostomy  in  order  to  pre- 
vent the  patient  from  starving  to  death.  The  object  of  this 
operation  is  to  form  a  permanent  gastric  fistula,  one  which 
will  not  leak  and  through  which  the  patient  may  be  fed.  The 
three  operations  known  by  the  names  of  the  men  who  first 
suggested  them — Senn,  Franck,  and  Witzell — are  the  ones 
generally  followed  and  all  admirably  accomplish  the  purpose 
for  which  they  were  designed.  After  such  an  operation  the 
patient  can  be  fed  on  any  easily  assimilated  liquid  food,  or 
upon  sohds,  if  the  precaution  is  taken  to  first  masticate  the 
food  thoroughly  in  the  mouth  before  it  is  introduced  through 
the  tube  into  the  stomach.  The  operation  of  gastrostomy  is 
not  a  dangerous  one,  provided  of  course  it  is  performed,  as 
should  always  be  the  case,  before  the  patient  reaches  a  stage 
of  extreme  cachexia.  The  results  from  the  operation  are 
generally  satisfactory — in  the  non-malignant  cases  life  may  be 
preserv'ed  indefinitely,  and  in  the  malignant  ones  the  relief 
from  pain  and  other  distressing  symptoms  is  sufficient  to  more 
than  justify  the  procedure. 

Cicatricial  Stenosis  of  the  Pylorus. — The  operation  of  pylo- 
rectomy  has  given  such  a  high  mortality  that  it  is  no  longer 
considered  advisable  except  in  cases  where  the  radical  cure 
of  carcinoma  is  to  be  attempted.  The  choice  of  operation 
depends  largely  on  the  conditions  as  they  reveal  themselves 
at  the  time  of  the  operation,  but  as  a  rule  a  radical  one  like 
gastro-jejunostomy  or  gastro-duodenostomy  will  give  the  best 
results,  and  unless  contra-indicated  should  always  be  given 
the  preference  over  the  plan  of  cutting  the  stricture  (pylo- 
roplasty), or  stretching  it  (pylorodiosis).  The  operation  of 
gastro-jejunostomy,  as  now  performed  with  sutures  and  spe- 
cially devised  clamps  for  holding  the  stomach  and  intestines, 
can  be  c^uickly  and  easily  done.  If  the  proper  technique  is 
observed,  regurgitant  vomiting  and  the  formation  of  the  so- 
called  vicious  circle  are  not  so  frequently  encountered  as  in 
former  days.     The  mortality  from  the  operation  should  not 


THE    SURGERY    OF    THE   STOMACH    AND   INTESTINES       989 

be  over  4  per  cent.  The  operation  of  gastro-duodenostomy 
as  perfected  by  Finney  and  Kocher  has  much  to  recommend 
it,  but  it  is  more  difficuh  to  perform  and  gives  a  higher  mor- 
tahty  than  gastro-enterostomy. 

Hour-Glass  Stomactu — This  is  usually  caused  by  the  ad- 
hesions following  a  gastric  ulcer, — occasionally  it  is  congenital 
or  the  result  of  syphilitic  gumma  or  cancer.  The  treatment 
is  entirely  surgical — in  many  cases  all  that  is  required  is  a 
plastic  operation  to  relieve  the  constriction  (gastro-plasty). 
In  other  cases  it  is  better  to  join  the  two  sacs,  by  an  anasta- 
motic  opening  (gastro-gastrotomy)  and  at  the  same  time,  if 
necessary,  do  a  gastro-jejunostomy. 

Cancer  and  Sarcoma  of  the  Stomach —  Primary  sarcoma  of 
the  stomach  is  hardly  rare  enough  to  be  considered  a  patho- 
logical curiosity,  the  literature  containing  the  report  of  50 
or  more  cases,  and  it  is  probable  that  there  are  many  more, 
sarcoma  not  infrequently  being  mistaken  for  carcinoma.  Gas- 
tric carcinoma  on  the  other  hand  is  very  common,  the  stomach 
standing  third  in  the  order  of  frequency  among  the  organs 
of  the  body  most  frequently  attacked  by  this  disease.  In  these 
conditions  of  the  stomach  surgery  can  occasionally  offer  the 
hope  of  a  complete  and  permanent  cure,  and  in  a  number  of 
cases  which  are  too  far  advanced  to  attempt  radical  work  a 
palliative  operation  like  gastro-enterostomy  will  sometimes 
prolong  life,  relieve  pain,  vomiting,  and  other  distressing- 
symptoms,  thereby  rendering  the  patient's  latter  days  decid- 
edly more  comfortable. 

The  value  of  an  early  diagnosis  cannot  be  too  strongly 
emphasized,  for  if  the  object  of  the  operation  is  to 
be  attained  and  a  complete  cure  effected,  it  is  abso- 
lutely necessary  that  the  work  be  done  before  extensive 
metastasis  has  taken  place  and  at  a  time  when  every  particle 
of  diseased  tissue  can  be  removed.  If  the  tumor  is  situated 
in  the  body  of  the  stomach,  a  radical  operation  necessitates 
the  removal  of  almost  the  entire  organ,  only  enough  of  the 
cardiac  end  being  left  to  form  an  anastomosis  with  the  jeju- 


990  THE    GASTRO-INTESTINAL    CLINIC 

num.  The  mortality  from  this  operation  is  high  and  but  few 
cases  come  to  the  operating-table  early  enough  to  justify 
attempting  it.  When  the  growth  involves  the  pyloric  orifice, 
as  it  does  in  the  majority  of  cases,  excision  is  easier  and  it 
is  not  considered  necessary  to  remove  so  much  of  the  stomach, 
but  precaution  should  always  be  taken  to  extend  the  incision 
high  enough  toward  the  cardiac  orifice  to  assure  the  removal 
of  the  entire  chain  of  glands  along  the  lesser  curvature. 

Dilatation  of  the  Stomach. — Acute  dilatation  is  a  very  fatal 
disease,  but  fortunately  it  is  not  often  encountered.  We  do 
not  fully  understand  its  pathogenesis,  but  from  a  clinical 
standpoint  know  that  it  is  very  closely  allied  to  ileus  and 
paresis  of  the  bowel.  In  about  40  per  cent,  of  the  reported 
cases  it  has  come  on,  generally  within  a  few  days,  after  some 
abdominal  operation  performed  under  general  anaesthesia. 
Some  other  causes  which  are  supposed  to  predispose  to  it  are 
over-eating,  chronic  wasting  diseases,  and  injuries  to  the  head 
and  spine. 

Treatment  so  far  has  proven  of  little  avail — early  and  fre- 
quent lavage  is  recommended,  but  unless  this  affords  prompt 
relief,  it  will  probably  be  better  to  perform  a  gastrostomy. 

Chronic  Dilatation  (Gastrectasis). — Constriction  at  the  pylo- 
ric orifice,  atrophy  of  the  tunica  muscularis,  and  continual  ex- 
cessive ingestion  of  food  and  drink  are  the  most  frequent 
causes  of  this  condition. 

Treatment. — Conservative  measures  should  first  be  given 
a  thorough  trial,  but  if  they  fail  to  afford  relief,  an  operation 
is  the '  only  alternative.  The  usual  surgical  procedure  is  to 
overcome  the  constriction  at  the  pyloric  orifice  (pyloroplasty) 
and  at  the  same  time  do  a  gastro-enterostomy.  If  the  stomach 
is  enormously  enlarged  a  row  of  interrupted  sutures  should 
be  placed  through  the  anterior  abdominal  wall  in  order  to  tuck 
in  some  of  the  excessive  tissue  (gastroplication). 

Gastroptosis. — A  downward  displacement  of  the  stomach 
may  result  from  some  congenital  deformity  or  may  accom- 
pany a  general  relaxation  of  all  the  abdominal  organs.     The 


THE    SURGERY    OF   THE   STOMACH    AND   INTESTINES      99I 

ligaments  and  various  mesenteric  attachments  are  lengthened, 
thus  permitting  the  liver  to  extend  below  the  costal  margin 
and  the  stomach  below  the  umbilicuS.  This  condition  fre- 
quently exists  without  producing  any  marked  disturbance  of 
the  digestive  process;  on  the  other  hand  it  will  often  render 
life  miserable.  A  great  many  cases  can  be  entirely  relieved 
by  wearing  an  abdominal  belt  made  so  as  to  lift  up  and  sup- 
port the  depressed  viscera,  at  the  same  time  proper  attention 
being  given  to  rest,  diet,  exercise,  etc.  Surgical  interference 
should  be  a  last  resort  and  advised  only  after  persistent  and 
repeated  failure  of  all  palliative  means.  The  operation  de- 
vised by  Dr.  Harry  D.  Beyea  of  Philadelphia  is  the  most  ra- 
tional one  and  the  one  which  up  to  the  present  time  has 
afforded  the  greatest  number  of  cures.  The  abdomen  is 
opened  through  the  middle  line  and  the  gastro-hepatic 
omentum  shortened  by  passing  through  it  from  above  down- 
ward a  series  of  interrupted  sutures.  The  sutures  are  intro- 
duced close  to  the  border  of  the  liver  and  each  bite  of  the 
needle  takes  up  about  one  inch  of  tissue,  finally  emerging  at  a 
point  just  above  the  border  of  the  stomach.  When  these 
sutures  are  tied,  the  effect  is  to  draw  up  the  stomach  and  fix 
it  in  its  normal  position. 

Foreign  Bodies  in  the  Stomach. — A  great  many  of  the  for- 
eign bodies  swallowed  intentionally  or  accidentally  cause  no 
harm  or  injury;  they  find  their  way  naturally  through  the 
pyloric  orifice  and  are  discharged  with  the  feces.  But  there 
are  some  which  cannot  be  so  eliminated  and  as  long  as  they 
remain  in  the  stomach  are  a  serious  menace  to  health  and 
life.  Before  any  operative  procedure  is  attempted,  an  x-ray 
picture  should  be  taken  so  as  to  render  the  diagnosis  abso- 
lutely certain;  a  simple  gastrotomy  can  then  be  performed 
and  the  substance  removed. 

Wounds  of  the  Stomach.^Stab  and  gun-shot  wounds  of  the 
abdomen  frequently  penetrate  the  peritoneal  cavity  and  injure 
the  stomach. 

Whenever  from  the  position  of  the  wound  there  is  suf^cient 


992  THE    GASTRO-IXTESTIXAL    CLINIC 

evidence  to  render  this  likely,  an  exploratory  operation  should 
be  immediately  made,  and  the  anterior  and  posterior  walls 
carefully  examined. 

SURGERY  OF  THE   INTESTINES 

Duodenal  Ulcers. — These  ulcers  pathologically  and  symp- 
tomatically  are  closely  allied  to  gastric  ulcers,  but  differ  in 
that  they  are  more  frequent  (six  to  one)  in  men  than  in 
women.  The  surgical  treatment  of  the  two  conditions  is  the 
same.  When  a  patient  suffers  from  localized  tenderness  in 
the  right  epigastrium,  with  pain  coming  on  from  one  to  three 
hours  after  eating,  has  vomiting,  blood  in  the  stools,  eructa- 
tions of  gas,  and  withal  a  gradual  and  progressive  loss  of 
weight,  the  diagnosis  of  duodenal  ulcer  is  justifiable.  The 
treatment  should  first  be  conservative  and  palliative,  every 
effort  being  made  to  effect  a  cure  by  means  of  rest,  massage, 
diet,  and  judicious  medication,  but,  if  after  the  patient  has 
been  under  observation  for  a  reasonable  time,  (two  to  four 
weeks),  and  there  is  no  improvement  noted,  operative  work 
should  be  advised.  One  of  the  most  important  factors  in  pre- 
venting the  ulcer  from  healing  is  the  constant  passing  of  the 
chyme  over  it;  a  gastro-enterostomy  obviates  this  by  providing 
means  of  diverting  the  food  directly  into  the  jejunum. 

The  most  serious  complication  of  duodenal  ulcer  is  per- 
foration, which  may  be  expected  in  from  25  to  30  per  cent, 
of  cases.  It  is  often  the  first  clinical  manifestation  of  the 
disease,  and  its  prompt  recognition  is  of  the  greatest  impor- 
tance. The  favorite  seat  of  rupture  is  in  the  first  portion  of 
the  duodenum,  on  the  anterior  wall  and  within  one  inch  of  the 
pyloric  orifice.  It  is  not  necessary  before  operation  to  waste 
time  trying  to  locate  the  exact  point  of  rupture;  if  the  history 
points  towards  duodenal  ulcer  and  one  finds  the  patient  suf- 
fering from  profound  shock,  severe  pain  in  the  epigastrium 
with  a  rigid  scaphoid  abdomen  and,  possibly,  diminution  of 
the  liver  dullness,  he  should  not  hesitate  to  urge  immediate 


THE   SURGERY   OF   THE   STOMACH    AND   INTESTINES      993 

operation.  The  reported  cases  prove  conclusively  that  suc- 
cess or  failure  depends  upon  the  time  elapsing  between  per- 
foration and  operation — those  cases  operated  upon  under 
twelve  hours  nearly  all  recover,  whereas  if  there  is  a  delay 
of  twenty-four  hours  or  more  nearly  all  of  them  die. 

In  operating  for  suspected  duodenal  ulcer  the  abdomen 
should  be  opened  above  the  umbilicus  through  the  right  rectus 
muscle  and  a  careful  and  systematic  search  instituted  in  order 
to  find  the  seat  of  trouble.  A  small  opening  with  but  little 
surrounding  induration  may  be  closed  by  a  continuous  Lam- 
bert or  a  purse-string  suture. 

If,  however,  one  finds  a  large  puncture  surrounded  by  a 
ring  of  indurated,  friable  tissue,  he  will  have  to  exercise  con- 
siderable ingenuity  to  successfully  close  it  without  seriously 
narrowing  the  lumen  of  the  bowel — if  possible,  two  rows  of 
interrupted  Lambert  sutures  should  be  used  and  over  this  a 
graft  of  omentum  placed. 

Tuberculosis  of  the  Intestines. — Probably  not  more  than 
one-tenth  per  cent,  of  the  adults  who  suffer  from  tuberculosis 
are  infected  primarily  along  the  intestinal  tract;  in  children 
it  is  much  more  frequent  (variously  estimated  at  from  i  to  4 
per  cent.).  Secondary  involvement  of  the  intestines  following 
pulmonary  tuberculosis  is,  on  the  other  hand,  a  common  oc- 
currence both  in  adults  and  children. 

Treatment  from  a  surgical  standpoint  centers  particularly 
about  the  primary  infections  localized  along  an  accessible  por- 
tion of  the  intestinal  tract,  chiefly  those  involving  the  region 
in  and  around  the  ileo-cecal  valve.  A  tumor-like  mass  gradu- 
ally developing  in  the  peritoneal  cavity  and  accompanied  by 
the  symptoms  of  intestinal  obstruction  demands  an  explora- 
tory operation.  The  abdomen  should  be  opened,  preferably 
through  the  median  line,  and  a  resection  done  in  all  cases 
where  it  seems  possible  to  remove  the  entire  tubercular  mass. 
The  reported  resuks  from  this  operation  are  highly  satisfac- 
tory, a  number  of  complete  cures  having  been  effected.  If 
it  does  not  seem  feasible  to  attempt  a  radical  operation,  then 


994  THE    GASTRO-INTESTINAL    CLINIC 

a  temporary  procedure  such  as  enteroplasty,  or  the  formation 
of  an  artificial  anus,  may  succeed  in  prolonging  life  and  ren- 
dering the  patient  more  comfortable. 

Intestinal  Tumors. — The  benign  tumors  are  exceedingly  rare 
and  practically  limited  to  adenomas,  fibrous  growths,  and 
liporjias.  They  are  of  surgical  interest  chiefly  because  they 
seem  to  predispose  to  intussusception.  Sarcomas  are  of  oc- 
casional occurrence,  the  lympho-sarcoma  being  the  most  usual 
form  of  it.  Carcinomas  are  common  along  the  whole  intes- 
tinal tract,  especially  so  in  the  duodenum  and  colon.  There 
is  no  more  difficult  and  important  diagnosis  in  medicine  than 
the  early  recognition  of  intestinal  carcinoma.  If  it  is  delayed 
until  the  mass  grows  large  enough  to  be  palpated  through  the 
abdominal  wall,  the  probabilities  are  that  a  radical  operation 
will  be  impossible. 

The  rule  should  be  that  if  the  symptoms  point  strongly 
toward  carcinoma  an  operation  is  indicated,  eveii  though  the 
confirmatory  presence  of  the  mass  is  absent.  The  abdomen 
should  be  opened  through  the  middle  line  and  a  careful  in- 
vestigation made  to  determine  the  nature  of  the  trouble.  If 
a  tumor  is  found  in  some  accessible  portion  of  the  intestinal 
tract,  it  must  first  be  carefully  studied  in  order  to  ascertain 
w^hether  or  not  its  complete  removal  is  possible.  In  case  a 
resection  is  decided  upon,  the  diseased  loop  of  bowel  is  drawn 
through  the  abdominal  wound  and  walled  off  from  the  peri- 
toneal cavity  by  gauze  sponges.  Precaution  should  always 
be  taken  to  see  that  the  line  of  incision  both  above  and  below 
the  mass  is  through  perfectly  healthy  tissue,  even  though  this 
may  necessitate  the  removal  of  cjuite  an  extensive  amount  of 
bowel.  The  form  of  anastomosis  depends  upon  the  conditions 
as  they  reveal  themselves  at  the  time  of  the  operation — the 
simplest  and  easiest  method  is  to  close  the  ends  by  a  purse- 
string  suture  and  invert  them  into  the  bowel  with  a  continu- 
ous Lambert  suture,  the  operation  being  completed  by  making 
a  lateral  anastomosis. 

If  a  colostomy  is  decided  upon,  it  can  be  performed  in  sev- 


THE    SURGERY    OF    THE   STOMACH    AND   INTESTINES       995 

eral  ways,  and  the  method  selected  depends  upon  the  patho- 
logical conditions  necessitating  the  operation.  Unless  contra- 
indicated  the  point  of  election  is  the  left  inguinal  region — • 
the  abdomen  is  opened  by  splitting  the  muscles,  the  highest 
portion  of  the  sigmoid  drawn  into  the  wound  and  fixed  there 
either  by  passing  a  glass  rod  through  the  mesocolon,  or  by  the 
use  of  the  Ward  stitch  tied  over  a  small  piece  of  drainage 
tube.  If  there  is  no  necessity  for  haste,  a  dressing  should  be 
applied  and  the  bowel  left  from  two  to  four  days  before 
opening.  But  in  case  immediate  evacuation  is  called  for,  it 
is  better  to  stitch  the  bowel  all  around  to  the  peritoneum, 
make  a  small  opening  at  the  crest  of  the  loop,  and  insert  a 
Paul's  tube — by  so  doing  the  dangers  of  infection  are  mini- 
mized. In  cases  where  it  is  certain  the  fistula  is  to  be  per- 
manent, some  surgeons  prefer  to  divide  the  bowel,  close  the 
distal  end,  and  drop  it  back  into  the  peritoneal  cavity;  the 
proximal  end  being  fastened  to  the  peritoneum  and  fascia 
with  catgut  sutures,  and  a  glass  drainage  tube  introduced  into 
the  bowel  to  drain  the  fecal  matter  away  from  the  wound. 

Intestinal  Obstruction. — There  are  many  mechanical  condi- 
tions originating  either  within  or  without  the  bowel  which 
may  give  rise  to  various  degrees  of  obstruction,  and  it  may 
also  result  from  an  intestinal  paralysis  which  follows  some 
local  or  general  disease.  Mention  has  already  been  made  of 
a  few  of  the  mechanical  causes  demanding  surgical  attention, 
such  as  cicatricial  contraction,  pressure,  and  distortion  from 
tumors,  etc.,  etc.  Other  causes  of  obstruction  which  will  be 
considered  here  are  biliary'  calculi,  intestinal  concretions, 
ascarides,  accumulation  of  feces,  intussusception,  volvulus, 
flexures,  and  strangulation  by  ligamentous  bands. 

Biliary  Calculi. — As  a  rule,  these  are  small  and  pass 
through  the  intestines  without  causing  any  serious  harm,  but 
now  and  then  an  unusually  large  one  will  lodge  along  the 
intestinal  tract  and  cause  trouble.  As  soon  as  the  diagnosis 
of  obstruction  is  made,  the  abdomen  should  be  opened  and  the 
position  of  the  stone  determined.     If  the  calculus  is  soft  it 


996  THE    GASTRO-INTESTINAL    CLINIC 

may  sometimes  be  crushed  with  the  fingers,  but,  unless  this 
can  be  done  without  injuring  the  bowel,  it  is  better  to  incise 
the  gut  at  once  and  remove  it.  A  method  recommended  by 
Tait  consists  in  piercing  and  breaking  up  the  enterolith  with 
a  strong  needle  passed  obliquely  through  the  intestinal  wall, 
the  ^mall  wound  being  afterwards  closed  by  a  few  interrupted 
sutures.  If  the  operation  has  been  delayed  too  long  and  the 
intestinal  wall  at  the  site  of  the  stone  has  become  gangrenous, 
a  resection  must  be  performed. 

Obstruction  due  to  intestinal  concretions,  an  accumulation 
of  feces,  masses  of  ascarides  or  other  worms,  resisting  all 
simple  and  ordinary  methods  of  treatment,  must  be  subjected 
to  operation  in  a  manner  similar  to  that  advised  for  obstruc- 
tion caused  by  gall-stones. 

Intussusception. — The  older  methods  of  attempting  a  reduc- 
tion by  means  of  inflation,  injections,  etc.,  are  now  generally 
regarded  as  a  waste  of  valuable  time;  consequently,  they  are 
being  abandoned.  The  invariable  rule  should  be,  unless  there 
is  some  strong  contra-indication,  to  do  a  laparotomy  as  soon 
as  possible  after  the  diagnosis  is  made.  The  intussusception 
can  generally  be  reduced  easily  by  gentle  traction  on  the  bowel, 
and  a  recurrence  prevented  by  fixing  it  with  a  few  interrupted 
sutures,  or,  if  necessary,  shortening  the  mesentery  at  the  site 
of  the  intussusception.  In  case  the  invagination  cannot 
be  reduced  and  the  bowel  is  gangrenous,  recourse  must 
be  had  to  a  resection  followed  by  either  an  end-to-end 
or  lateral  anastomosis.  In  chronic  cases  with  the  bowel  in 
good  condition,  a  short-circuiting  operation  is  all  that  is 
necessary. 

Volvulus  is  characterized  by  a  rapid  onset,  profound  shock, 
and  all  the  symptoms  of  complete  obstruction.  The  abdomen 
should  be  opened  without  delay  and  the  affected  loop  un- 
twisted. There  is  great  danger  of  recurrence  and  conse- 
quently every  precaution  should  be  taken  to  guard  against 
it.  It  may  be  necessary  to  shorten  the  mesentery,  to  stitch 
the  bowel  to  the  anterior  abdominal  wall  or  to  the  side  of  the 


THE    SURGERY    OF    THE    STOMACH    AND    INTESTINES       997 

pelvis.     If  the  affected  loop  is  gangrenous,  a  complete  resec- 
tion is  demanded. 

Intestinal  Flexure. — The  bowel  should  be  straightened  out, 
and  to  prevent  a  recurrence  a  V-shaped  piece  should  be  re- 
moved from  the  wall  of  the  affected  loop  and  the  wound 
closed  by  sutures. 

Adhesions  and  Ligamentous  Bands. — These  should  be  cut 
between  two  ligatures  and,  if  large,  the  raw  ends  covered  with 
peritoneum. 

Meckel's  Diverticnlum. — This  anatomical  anomaly  will  oc- 
casionally cause  intestinal  strangulation.  It  should  be  removed 
in  the  same  way  that  an  appendectomy  is  done. 

Hernia. — Strangulation  of  any  internal  hernia  demands  an 
immediate  laparotomy  as  soon  as  the  diagnosis  is  made.  A 
strangulated  external  hernia  protruding  under  the  skin  can 
frequently  be  reduced  by  taxis,  but  one  should  not  persevere 
with  this  form  of  treatment  longer  than  ten  or  fifteen  min- 
utes— operative  intervention  is  generally  required. 


INDEX 


Abdomen,  contra-indications  for  mas- 
sage of,  274 
indications   for  massage  of,   273 
inspection   of,  76 
splashing  sounds  in,    186 
strapping  for  displacements,  423 
Abdominal  cavity,  anatomy  of,  31 
displacements  as  causes  of  pelvic 

disease,  462 
organs,  how  mapped  out,  70 
tumors,  differential  diagnosis  of 

gastric   cancer    from,  628 
tympany,  187 
Abram's       method       of       treatment 
through    the    spine,   311 
method   of  treatment  of   consti- 
pation, 783 
Abscess,  ischiorectal,  912 
of  rectum,,  gii 
subphrenic,  541 
Absorption,    59 

defecation   and   digestion,   physi- 
ology of,  54 
Acetone  and  diacetic  acid,  158 

iodoform  test  for,  159 
Achylia  gastrica,  symptoms  of,  833 
Acid,  diacetic,   158 

gastric  catarrh,  diagnosis  of,  509 
gastric    catarrh,    diagnosis    from 

ulcer,  511 
gastric  catarrh,  aetiology  of,  504 
gastric  catarrh,  microscopic  help 

in,  diagnosis  of,  512 
gastric  catarrh,  pathology  of,  505 
gastric  catarrh,  symptoms  of,  506 
gastritis,  485 
gastritis  and  HCl  excess,  diet  in, 

gastritis  and  HCl  excess,  medic- 
inal treatment  in,  522 


Acid  gastritis  and  HCl  excess,  treat- 
ment of,  514 
hydrochloric,   an   injurious   rem- 
edy in  certain  cases,  2^3 
hydrochloric,    does    not    prevent 

fermentation,  334 
hydrochloric,  valuable  effects  of, 

335 
lactic,  test  for,  127 
uric,  tests  for,  153 
Acids,  administration  of,  331 
organic,  excess  of,  531 
organic,  tests  for,  128 
Acute  appendicitis,  treatment  of  the 
severer  forms,  757 
catarrhal   appendicitis,   treatment 

of,   755 
•catarrh  of  the  intestines,  aetiology 

of,   707 
enteritis,  diagnosis  of,  710 
enteritis,  diet  in,  714 
enteritis,  pathology  of,  708 
enteritis,  prognosis  of.  711 
enteritis,  symptomatology  of,  709 
enteritis,  treatment  of,  711 
gastrectasis,   387 
gastritis,  simple,  diagnosis  of,  473 
gastritis,  treatment  of,  474 
Adhesions,    surgical    treatment,    987 

perigastric,   987 
Administration  of  acids,  331 
Advantages   claimed   for   mechanical 

vibration,    305 
Etiology,  incidence,  etc.,  of  sarcoma 

of  the  stomach,  617 
After-treatment   of  membranous  ca- 
tarrh of  the  intestines,  819 
Age  and  sex,   incidence  of  ulcer  as 

to,  534 
Air  passages,  upper,  blood  from,  600 


999 


lOOO 


INDEX 


Albumin,  tests  for,  131 

Alcohol  and  food  accessories,  195 

rarely  necessary,  355 
Alcoholic  gastritis,  481 

liquors,  effects  of,  230 
Alimentation,  rectal,  technique  of,  248 
Alkalies   and   alkaline   spring   waters 
in  hyperchlorhydria,  531 

for  acid  gastritis,  522 

effect  of,  given  before  and  after 
meals,  330 

in  gastro-intestinal  disease,  348 
Alkaline  mineral  waters,  349 
American  surgery,  tribute  to,  462 
Amceba  coli,  941 

dysenterise,   illustration  of,  803 
Amoebic  dysentery,  complications,  804 

dysenterjs  diagnosis  of.  804 

dysentery,  setiology  of,  802 

dysentery,  pathology  of,  803 

dysentery,  prognosis  of,  805 

dysentery,  symptoms  of,  804 

dysentery,  treatment  of,  805 
Ammonium  benzoate  as  an  antisep- 
tic, 362 
Anacidity     of     the     stomach,     nerv- 
ous,   833 
Anadenia,  gastrica,  833 
Analyses,  fees  for,  143 

quantitative,  indispensable  to  di- 
agnosis of  acid  gastritis,  514 
Anaemia   and   chlorosis,   954 

as  predisposing  cause  of  gastric 
ulcer.   550 

pernicious,    from    septic    mouth, 
825 
Anatomy  of  abdominal  cavity,  31 

of  cecum,  42 

of  digestive  tract,  29 

of  duodenum,  41 

of  intestinal  canal,  41 

of  intestines,  liver,  etc.,  41 

minute,  of  the  stomach,  37 

of  pharynx,  29 
Aneurismal     and    atheromatous 

changes  in  the  arteries,  545 
Animal  parasites  in  feces,  168 


Ankylostoma  duodenale,  942 

Anomalous  course  of  first  portion  of 
ascending  colon,  445 
direction  of  transverse  colon,  452 

Anorexia  and  hyperkoria,  848 
(impaired   appetite),    179 

Antiseptic  drugs  for  fermentation,  827 

Anus,  fissure  of,  909 

Apparatus  for  lavage,  314 

Appendicitis,  chronic  catarrhal,   T})"] 
chronic  catarrhal,  symptoms,  738 
chronic  catarrhal,  diagnosis,  739 
chronic,  as  a  source  of  flatulency, 

824 
clinical  course  of,  736 
complicated  by  peritonitis,  734 
conservative      surgical      method 

in,    743 
diet    in,    746 

different  forms  of,  728,  729 
diagnosis   of,   735 
setiology  of,  729 
fulminating  form  of,   ^2)7 
latent  chronic  cases  of,  738 
lavage  in,  745 
management  of,  762 
non-operative  treatment  of,  often 

the  only  kind  practicable,  758 
nutritive  enemas  for,  746 
Ochsner's      description     of     his 

method   in,   745 
Ochsner's  plan  of  treating,  744 
operative  treatment  for,  747 
pathology  of,  730 
perforation  in,  734 
physical   signs  of,  736 
prognosis  of,  740 
radical  surgical  method  in,  743 
rectal  temperature  in,   most  sig- 
nificant, 734 
report  of  author's  case  of,  760 
report    of    Babcock's    operations 

for,  749 
report  of  Deaver's  work  in,  750 
Richardson's  results  in,  748 
salicylic    enemas    for,    765 
simple  classification  of,  729 


INDEX 


lOOI 


Appendicitis,  symposium  on,  754 
symptoms  of,  732 
the   pulse   in,    734 
treatment  of  acute  catarrhal,  755 
treatment    of    chronic    catarrhal, 

759 
treatment    of   the    severer    forms 

of,  757 
Appendix,  glands    and  lymphoid  tis- 
sue from,  42 
often  involved  in  diarrhea,  788 
directions  for  palpating,  739 
removal  of,  during  first  36  hours, 

742 
surgery    of,    743 

thickening  of,   in  chronic  enteri- 
tis,  719 
Appetite,  excessive,  180,  845 
excessive,  causes  of,  845 
impaired  (anorexia),  179 
normal  excitants  of,  196 
Applications  to  abdomen  in  intestinal 
colic,  8go 
to   epigastrium   in  nervous   vom- 
iting, 861 
Approximate  quantitative  test  for  in- 

dican,  151 
Area  of  tympany  in  gastrectasis  with 
gastroptosis,  401- 
of  tympany  in  gastroptosis,  434 
Arnold's    claims    for    manual    ther- 
apy, 307 
Aromatic  sulphates  in  the  urine,  149 
Arrangement  of  meals  with  relation 

to  rest  and  exercise,  211 
Arsenite  of  copper  as  a  remedy  in 
gastro-intestinal  affections,  366 
Arteriosclerosis     and     its     relations 
with      gastro-intestinal      affec- 
tions,   970;    climatotherapy    in, 
985;     diagnosis    of,    976;    eti- 
ology    of,     974;     of     the    ab- 
dominal   vessels,    972 ;    pathol- 
ogy of,   975 ;    prophylaxis  and 
treatment    of,    980. 
Astringents,   362 
Atonic  and  spastic  constipation,  771 


Atonic  conditions,  diet  in,  219 

constipation,   differential   diagno- 
sis between  spastic  and,  769 
constipation,  Penzoldt's  diet  for, 

778 
dilatation  of  stomach,   treatment 
of,  410 
Atony,  gastric,  378 

of  stomach,  aetiology  of,  381 
of  stomach,  diagnosis  of,  383 
of  stomach,  nervous,  865 
of  stomach,   symptomatology  of, 

382 
of  stomach,  symptoms  of,  381 
relative  importance  of  dilatation 

and,  379 
various  degrees  of,  380 
Atropine,    great    value    of,    in    acute 

ileus,  700 
Atrophy  of  the  mucous  membrane  of 
stomach  with  polyposis,  490 
of  the  stomach,  diagnosis  of  can- 
cer  from,   626 
Auscultation  and  percussion,  85 
Author's  case  of  appendicitis,  760 
method  of  determining  the  state 
of    the    gastric    motor    func- 
tion, 90 
method    of   outlining   the    stom- 
ach, go 
results    from    mechanical    treat- 
ment   of    abdominal    displace- 
ments, 666,  668 
Auto-intoxication   as   a   cause  of   in- 
somnia, 967 
Autotoxic  nephritis  treated  by  elec- 
tro-static currents,  283 


Babcock's    operations    for    appendi- 
citis, 749 
paper  on  coloptosis,  440 
Bacillary  dysentery,  aetiology  of,  798 
dysentery,       complications      and 

sequels  of,  799 
dysentery,  definition  of,  798 
dysentery,  diagnosis  of,  799 


I032 


INDEX 


Bacillary  dysentery,  pathology  of,  798 

dysentery,  treatment  of,  800 
Bacillus  butyricus,  141 

Flexner,   of   dysentery,  808 
Shiga-Kruse,  808 
Bacteria  and  animal  parasites  in  gas- 

tro-intestinal    tract,   931 
Baths  of  warm  milk,  252 
Bead    test,    Einhorn's,    134 
Bedford  Spring  water,  350 
Belched  gas  from  the  intestines,  823 
Benedict  effervescent  test  for  gastric 
acidity,  132 
effervescent  test,  further  develop- 
ment of,   132 
Benign  tumors  of  the  rectum,  923 

tumors  of  the  stomach,  618 
Beverages  allowed  in  chronic  gastric 
catarrh.  498 
helpful   in   treatment   of  chronic 
gastritis,  498 
Bile,  58 

blood,  feces,  or  pus  in  the  stom- 
ach contents,  123 
Biliary  calculi,  treatment  of,  995 

pigments  and  acids,  156 
Bismuth  and  its  combinations  in  ex- 
cessive eructations,  827 
and  cerium  oxalate,  359 
in  chronic  asthenic  gastritis,  502 
preparations  in  gastric  ulcer,  359 
preparations    used    in    gastro-in- 

testinal  affections,  362 
treatment  of  gastric  ulcer,  555 
Bland  oils,  360 
Blood  cells,  red,  in  feces,  168 
counts,   176 
diseased  conditions  that  may  be 

diagnosed  by,   178 
examinations    not    conclusive    in 

stomach  cases,  173 
found  in  the  stools,  source  of,  597 
from    stomach    and    that    from 

lungs  or  air  passages,  600 
in  both  vomit  and  stools,  598 
in  gastric  carcinoma,  174 
in  gastro-intestinal  diseases,  173 


Blood  in  stomach  contents,  123 

in  vomit  and  stools,  significance 

•of,  595 
iron  test  for,  599 
specimen  of,  to  obtain,  175 
the,  in  gastric  cancer,  606 
Blood-vessels  in  the  stomach,  38 
Boas  bacilli  in  gastric  cancer,  613 
Boas'     explanation    of    aetiology    of 
constipation,  768 
formula    for   a   nutritive   enema, 
250 
Bodenhamer's  bivalve  speculum,  898 
Bothriocephalus  latus,  938 
Boundary,  mapping  out  the,  97 
Bowel,  measures  to  combat  collapse 
from  sudden  emptying  of,  291 
hydro-electric  curents  within,  288 
Bowels,   relief   of  pain   or   insomnia 

produced  by  disease  of,  355 
Breakfast,    Ewald,   117 
Breath,    fetor    of,    or    foul    taste    in 

mouth,  179 
Bright's   disease   and   diabetes,   influ- 
ence on  digestion,  968 
Bromides,  large  doses  of,  in  cardio- 
spasm, 855 
Bronzing,  jaundice  or  discolorations 

of  skin,  181 
Buccal  reflex,  846 
Bulimia  and  akoria,  845 

(excessive  appetite),  180 
Burette  for  quantitative  analysis,  il- 
lustration of,   135 


Caird,  F.  M.,  cases  of  tuberculosis  of 
cecum,  reported  by,  705 

Calculi,     biliary,     surgical    treatment 
of,   995 

Cancer  and  sarcoma  of  the  stomach, 
surgical  treatment  of,  989 
as  affected  by  its  location,  symp- 
toms of,  613 
gastric,  differential  diagnosis 
from  other  abdominal  tumors, 
629 


INDEX 


1003 


Cancer,     gastric,     hemorrhage    from, 
616 

■gastric,  histologic  changes  in, 
623 

gastric,  indications  for  an  ex- 
ploratory  incision  in,  643 

gastric,  operative  treatment  of, 
641,  989 

gastro-intestinal,  early  diagnosis 
most  important,  639 

of  body  of  stomach,  616 

of  cardia,  614,  615 

of  cardia  differentiated  from  ul- 
cer, 631 

of  gastric  walls,  616 

of  stomach,  complications,  se- 
quels, etc.,  606 

of  stomach,  diffuse,  605 

of  stomach,  frequency  and  inci- 
dence of,  602 

of  posterior  wall  of  the  stomach, 
604 

of  pylorus,  614 

of  stomach,  pathology  of,  603 

of  stomach,  varieties  of,  603 

of  stomach.  X-rays,  radium,  etc., 
in,  636,  641,  642,  643 
Capacity    and    motor  -power    of   the 
stomach,  103 

of  the  stomach,  tests  of,  103 
Capillaries  in  villus   of  injected   in- 
testine, 41 
Carbolic  acid  and  creosote  for  eruc- 
tations, 827 

safe  only  when  gastric  se(5retion 
not  excessive,  361 
Carbon  dioxide  in  diseases  of  the  rec- 
tum and  colon,  296 

in  intestinal  diseases,  296 
Carcinoma  and  sarcoma  of  intestines, 
aetiology  of,  652 

gastric  symptomatology  of,  609 

and  other  tumors  of  the  stomach; 
medicinal  and  palliative  treat- 
ment of,  644 

intestinal  metastases  of,  653 

of  the  cecum,  differential  diagno- 


sis   between    tuberculosis   and, 

663 
of  stomach  developed  in  site  of 

ulcer,  542 
of  stomach,  treatment,  645 
of   stomach,    treatment   with   X- 

rays,  636-639 
strictures    from,   obstructing   the 

bowels,  674,  701 
Carcinomatous     stenoses,     symptoms 

of,  701 
ulcer,  633 
ulcer    of   duodenum,    illustration 

of,  564 
ulcer  of  stomach,  625 
ulcer     of     stomach,     therapeutic 

test  for,  634 
Cardia,  cancer  of,  614 

cancer  of,  diffei»entiated  from  ul- 
cer, 631 
spasm  of,  852 
Cardiac  glands  from  a  dog's  stomach, 

34 
end    of    stomach,    glands    from, 

35 
Catarrhal    appendicitis,    acute,    treat- 
ment of,  755 
appendicitis,  chronic,  ^yj 
appendicitis,    chronic,    treatment 

of,  759 
dysentery,  diagnosis  of,  796 
dysentery,  aetiology  of,  794 
dysentery,  pathology  of,  794 
dysentery,  prognosis  of,  796 
dysentery,    saline    laxatives,    best 

remedies  for,  363 
dysentery,  symptoms  of,  795 
dysentery,  treatment  of,  796 
ulcers  of  intestines,  586 
Catarrh,  chronic  gastric,  prognosis  of, 

495 
chronic   intestinal,    from    cardiac 

or  hepatic  disease,  716 
chronic   intestinal,    diagnosis   of, 

720 
chronic   intestinal,   pathology  of, 

716 


1004 


INDEX 


Catarrh,  chronic  intestinal,  prog- 
nosis of,  721 

chronic  intestinal,  symptomatol- 
ogy of,  717 

chronic  intestinal,  treatment  of, 
772 

gastric,  diagnosis  of,  from  ner- 
vous dyspepsia,  875 

of    intestines,    chronic,    eetiology 

of,  71S 

of  intestines,  acute,  aetiology 
of,  707 

of  intestines,  membranous,  af- 
ter-treatment of,  819 

of  intestines,  membranous,  diag- 
nosis of,  812 

of  intestines,  membranous,  aetiol- 
ogy of,  810 

of  intestines,  membranous,  pa- 
thology of,  812 

of  intestines,  prognosis  of,  814 

of  intestines,  membranous  symp- 
toms of,  811 

of  intestines,  membranous,  symp- 
tomatic treatment  of.  814 

of  intestines,  membranous,  treat- 
ment of,  814 
Causal  treatment  of  membranous  ca- 
tarrh of  intestines,  815 
Causation       of       peristaltic       unrest, 

851 
Causes  of  dilatation  of  stomach,  388, 

389 

of  meteorism.  884 
Cecum,  anatomy  of.  42 

carcinoma  of,  differential  diagno- 
sis between  tuberculosis  and, 
663 

catarrh    of,    splashing    sound    in, 
719 
Cells,  border,  and  parietal  or  oxyntic 
cells,  36 

chief  or  central.  36 

goblet,  and  glands  from  the 
colon,  43 

red  blood,  in  feces,  168 

vegetable,  in  feces,  167 


Central  galvanization,  illustration  of, 

279 
Cerium  oxalate,  and  bismuth  prepara- 
tions, 359 
Chair    exercise    for    arm    and    trunk 

muscles,  illustration  of,  263 
Chlorides,  importance  of  estimating, 

145 
Chloride  waters  (saline),  351 
Cholera,    diagnosis   of  the   forms   of 

acute  enteritis  from,  711 
Chronic  appendicitis  as  a  source  of 
flatulency,  824 
catarrhal  appendicitis,  ']2)'j 
catarrh  of  the  intestines,  setiology 

of,  715 
dilatation  of  the  stomach,  388 
diarrhea,  diet  in,  790 
dysentery,  complications  of,  806 
dysentery,  diagnosis  of,  806 
dysentery,  pathology  of.  805 
dysentery,  prognosis  of,  806 
dysentery  symptoms  of,  805 
dysentery,  treatment  of,  806 
gastric     catarrh,     beverages     al- 
lowed in,  498 
gastric     catarrh,     prognosis     of, 

495 

gastric  catarrh,  treatment,  die- 
tetic and  hygienic,  496 

gastritis,  diagnosis  of,  492 

gastritis,  diagnosis  of  cancer 
from.  625 

gastritis,  different  forms  of,  485 

gastritis  in  general,  pathology  of, 
4S8 

gastritis,  symptomatology  of,  489 

gastritis,  syphilitic,  579 

intestinal    catarrh,    treatment    of, 

"722, 

intussusception,  701 
Cicatricial    stenosis    of   the    pylorus, 

972 
Clapotement   in   the   examination    of 

the  stomach,  96 
Classes    of   cases    for   which    certain 

diet  lists  are  indicated,  240 


INDEX 


1005 


Classification  of  diseases,  371 

of  diseases  with  regard  to  dietetic 

treatment,  216 
of  foods,  197 

of  intestinal  obstruction,  668 
Cleaves'   method   of  applying  hydro- 
electric treatment  in  the  bow- 
els, 289 
Climatic  changes  for  constipation,  780 
and  hygienic  measures  in  tuber- 
cular ulcerations  of  the  gastro- 
intestinal tract,  575 
Clinical  course  of  appendicitis,  736 
Cod-liver  oil  in  tuberculosis  of  stom- 
ach, 576 
Coffee  and  tea,  231 

Cohn's  method  of  applying  static  elec- 
tricity in  constipation,  286 
Cold  and  heat  as  remedies,  309 
Coldness  of  hands  and  feet  indicates, 
derangement  of  circulation,  TJ^ 
Colica    mucosa,     associated    oftenest 
with  hyperchlorhydria,  810 
mucosa.   Da  Costa's  early  study 

of,  809 
mucosa,    Nothnagel's    view    con- 
cerning, 810 
mucosa.    Von    Noorden's    mono- 
graph on,  809 
mucosa   in   true   enteritis,    treat- 
ment of,  820 
Colic  form  of  intussusception,  treat- 
ment of,  683 
intestinal,  882 
Colitis,  bismuth  and  oil  enemas  for, 
303 
treatment  of,  per  rectum,  789 
Colloid  cancer  and  tubercle  of  cecum, 

703 
Colon,  anatomy  of,  43 

carbon  dioxide  in,  296 

flushing  the,  301 

inflation  of,  99 

stomach,  etc.,  reports  of  cases  of 
displacements  of,  464 

Turck's   method   of   doing   mas- 
sage of,  301 


Colonic  irrigation  for  colitis,  714 
Coloptosis,  440 

diagnosis  of,  454 

seven  cases  cited  with  diagram- 
matic   illustrations,   444 
symptoms  of,  453 
treatment  of,  454 
Columnar   cells   and   yeast   fungi,   il- 
lustration  of,   508 
Combination  of  external  methods,  gi 
Comments     on     the    Von     Noorden 

method,  818 
Comparison    of    results    from    surgi- 
cal  and  mechanical   treatment, 
468 
Complications    and    consequences    of 
gastric  dilatation,  394 
and  course  of  tumors  of  the  in- 
testines, 660 
and    sequels    of   bacillary   dysen- 
tery, 799 
and     sequels     of    gastric    ulcer, 

treatment  of,  556 
and  sequels  of  round  ulcer  of  the 

duodenum,  563 
of  amcEbic  dysentery,  804 
of  chronic  dysentery,  806 
of  gastric  ulcer,  540 
sequels,    etc.,    of    cancer    of    the 
stomach,  606 
Compounds,  useless  pepsin,  347 
Concerning  test  meals,  117 
Concretions,  intestinal  obturation  by, 

673 

Conditions,  diseased,  that  may  be  di- 
agnosed by  the  blood,  178 

Congenital  anomalies  of  the  stomach, 
438 
stenosis  of  the  pylorus,  438 
stenosis  of  the  pylorus  generally 
fatal,  439 

Congo-red  paper  not  a  reliable  test 
for  free  HCl,  529 

Consequences    and    complications   of 
gastric  dilatation,  394 

Conservative  surgical  method  in  ap- 
pendicitis, 743 


ioo6 


INDEX 


Constriction  of  loop  of  intestine  by 
adhesion,  686 
of  intestine  by  club-shaped  diver- 
ticulum, 688 
Constipation,  i8o 
^Etiology  of,  766 
and  diarrhea,  alternating,  717 
as  a  symptom  of  rectal  diseases, 

894 
atonic  and  spastic,  differential  di- 
agnosis between,   769 
atonic,  Penzoldt's  diet  for,  778 
atonic     and     spastic     forms     of, 

767 
causes  of,  in  rectum,  etc.,  901 
complicated   by   enteritis,   mucus 

in,  ITi 
complicated    by    enteritis,    treat- 
ment of,  776 
dietetic  treatment  of,  778 
diet  in,  222 

dependent  on  displaced  right  kid- 
ney, 690 
from  organic  obstructions,  772 
gastric  functions  in,  782,  783 
in  nervous  dyspepsia,  878 
influence  of,  upon  the  blood,  955 
intra-rectal  vibration   for,   ']'j'] 
prognosis  of,  774 
rectal  relations  of,  901 
stools  in  atonic  and  spastic,  771 
symptomatology  of,  767 
treated  by  spring  water  and  sa- 
line laxative  drugs,  776 
■  treatment  of,  775 
treatment  of,  in  nervous  dyspep- 
sia, 878 
Continuous  current   (galvanism),  278 
hypersecretion  (Reichmann's  dis- 
ease), 528 
Contra-indications    for    the    stomach 

tube,  114 
Contra-indications  for  massage  of  the 

abdomen,  274 
Contraction,  hour-glass,  436 
Corset,   the,    as   cause   of   atony   and 
dilatation  of  the  stomach,  382 


Corset,  the,  as  cause  of  displacements 

of  stomach,  382 
Counter-irritants,  308 
Course  and  complications  of  tumors 
of  the  intestines,  660 
and      direction     of     the      spinal 
nerves,  49 
Creosote  and  cod-liver  oil  in  phthisis, 
959 
minute     doses     of,     in     irritable 
stomach,  of  tuberculosis,  574 
Crystals,  hemin,  examination  for,  599 

in  feces,  172 
Cupric    arsenite    in    gastro-intestinal 

affections,  366 
Curative  treatment  of  gastric  ulcer, 

S5I 
Currents,  action  of  faradic  on  gastric 
secretion    discovered    acciden- 
tally, 326 
continuous,  278 
high-frequency,  283 
induced,  280 
polyphase,  285 
Cylindric  cells  in  gastric  mucosa,  36 


Dangers   in   over-restriction   of   diet, 

224 
Deardorff's  antiseptic  enema,  724 

method  of  treating  chronic  colitis, 
302 
Deaver's     statistics     in    appendicitis, 

741,  750 
Debility,  181 

in   carcinoma,   measures  against, 
648 
Deductions  from  statistics  of  appen- 
dicitis, 751 
Defecation,  61 

absorption  and  digestion,  physi- 
ology of,  54 
painful,  181 
Definition  of  bacillary  dysentery,  798 

of  dysentery,  793 
Depression,  mental  or  nervous,  182 
Derangements  of  the  appetite,  844 


INDEX 


1007 


Determination  of  the  gastric   motor 

power,  98 
Detritus  in  feces,  172 
Diagnosis  and  symptoms  of  sarcoma 
of  the  stomach,  617 
differential,   between    atonic   and 

spastic  constipation,   769 
differential,  of  acute  ileus,  693 
differential,    between     carcinoma 

and  ulcer  of  stomach,  630 
differential,  of  dilatation  of  stom- 
ach, 402 
differential,     of     gastric     cancer 
from  other  abdominal  tumors, 
628 
differential,  between  gastric  ulcer 
and  the  diseases  which  resem- 
ble it,  546 
differential,  between  tuberculosis 

and  carcinoma  of  cecum,  663 
differential,       between       various 
forms    of    intestinal     obstruc- 
tion, 698 
early,  indispensable  in  the  treat- 
ment  of  gastro-intestinal  can- 
cers, 639 
of  acid  gastric  catarrh,  509 
of  acid  gastric  catarrh  from  ul- 
cer, SI  I 
of  achylia  gastrica,  834 
of  acute  enteritis,  710 
of  amoebic  dysentery,  804 
of  anorexia,  849 
of  appendicitis,  735 
of  atony  of  stomach,  383 
of  bacillary  dysentery,  799 
of  carcinoma  of  the  rectum,  926 
of  cardiospasm,  853 
of  catarrhal  dysentery,  796 
of  chronic  dysentery,  806 
of  chronic  gastritis,  492 
of  chronic  intestinal  catarrh,  720 
of  coloptosis,  454 
of    dilatation     of    the     stomach, 

396 
of  fistula  in  ano,  914 
of  gastralgia,  837 


Diagnosis    of    gastric  hypersesthesia, 
842 
of  gastric  phlegmon,  483 
of  gastroptosis,  433 
of  hemorrhage  from  stomach  and 

intestines,  598 
of  intestinal  ulceration,  590 
of  ischiorectal  abscess,  913 
of  membranous  catarrh  of  the  in- 
testines,  812 
of  meteorism,  885 
of  movable  kidney,  421 
of  nervous  dyspepsia,  874 
of  nervous   dyspepsia   from  gas- 
tric catarrh,  875 
of      nervous      dyspepsia      from 
hyperchlorhydria,  anacidity,  or 
hypochlorhydria,  875 
of  nervous  vomiting,  861 
of  Reichmann's  disease  from  gas- 
tric ulcer,  529 
of  round  ulcer  of  the  duodenum, 

562 
of  simple  acute  gastritis,  473 
of  stricture  of  the  rectum,  920 
of  toxic  gastritis,  480 
of  tubercular  ulcers  in  the  stom- 
ach and  intestines,  570 
of  trichinosis,  950 
of  tumors  of  intestines,  661,  664 
of   ulcer    of   the    stomach    from 

ulcer  of  the  duodenum,  545 
symptomatic  guide  to,  179 
Diaphragmatic  hernia,  684 
Diarrhea,   181 

aetiology  of,  784 
appendix  often  involved  in,  788 
as  a  symptom  of  constipation,  769 
as  a  symptom  of  rectal  disease, 

89s 
astringents     harmful     in     early 

stages  of,  714 
chief  symptom  of  acute  intestinal 

catarrh,  709 
chronic,  diet  in,  790 
colon    flushing   in   treatment   of, 

787 


ioo8 


INDEX 


Diarrhea  complicated  by  chronic 
appendicitis,  treatment  of, 
791 

complicating  conditions  in,  787 

diet  in,  222 

diet    for,    judged   by    results    on 
stopls,  791 

foods  which  aggravate  most,  790 

need  of  examining  stomach  con- 
tents and  urine  in,  787 

nervous  forms  of,  792 

opium  and  astringents  not  often 
needed  in,  787 

small    doses    of    podophyllin    in, 
788 

treatment  of,  785 

laxatives   in  treatment  of,  786 
Diathesis,  uratic,  diet  in,  225 
Dietaries,  American,  199 
Diet  and  dietotherapy,  204 

dangers    in     over-restriction     of, 
224 

directions    of    Leube    and    Pen- 
zoldt,  242 

in  acid  gastritis  and  HCl  excess, 

515 
in  acute  enteritis,  714 
in  atonic  conditions,  219 
in  appendicitis,  746 
in  cardiospasm,  854 
in  cases  of  movable  kidney,  427 
in  chronic  diarrhea,  790 
in     chronic     intestinal     catarrh, 

722 
in  chronic  asthenic  gastritis,  496 
lists,   classes  of  cases  for  which 

certain,  are  indicated,  240 
in  constipation,  778 
in  diarrhea  and  constipation,  222 
in  dilatation  from  pyloric  spasm, 

406,  408 
in  excessive  eructations,  827 
in  gastric  ulcer,  551 
in  irritative  conditions,  217 
in  nervous  vomiting,  861 
in  the  treatment  of  gastric  dila- 
tation, 388,  406,  407,  408 


Diet  in  the  uratic  diathesis,  225 

non-stimulating,  best  for  sthenic 

gastritis,  516 
normal,  table  of,  198 
Penzoldt's,   for  atonic    constipa- 
tion, 778 
scheme,  Leube' s,  242 
tables,   Penzoldt's,  244 
Dietetic    and    hygienic    treatment    of 
chronic  gastric  catarrh,  496 
faults,  frequent  cause  of  gastro- 
intestinal disease,  207 
sins,  how  to  detect,  68 
treatment,    classification    of    dis- 
eases with  regard  to,  216 
treatment    of    carcinoma    of   the 

stomach,  645 
treatment  of  membranous  catarrh 
of  the  intestines,  815,  816,  817 
Dietetics,      relative     importance     of, 

205 
Different   mechanical   methods,   simi- 
larity of  effects  of,  310 
Differential  diagnosis  of  acute  ileus, 

693 

diagnosis  of  dilatation  of  stom- 
ach, 402 

diagnosis  of  gastric  cancer  from 
other  abdominal  tumors,  628 

diagnosis  of  gastric  ulcer  and 
diseases  which  resemble  it,  546 

diagnosis  between  atonic  and 
spastic  constipation,  769 

diagnosis  between  tuberculosis 
and  carcinoma  of  the  cecum, 
663 

diagnosis  between  various  forms 
of  intestinal  obstruction,  698 
Difficulty  of  diagnosing  chronic  gas- 
tritis, 494 
Digestants,  345 

Digestive    capacity,     Penzoldt's    diet 
tables  for  gradual  training  of, 
244 
Digestion,  absorption,  and  defecation, 
physiology  of,  54 

gastric,  55 


INDEX 


1009 


Digestion,     impaired,     conducive     to 
tuberculosis,    956 
influence  of  Bright's  and  diabetes 

on,  968 
intestinal,  57 
salivary,  54 
salivary,  tests  for,  129 
Digestive  tract,  anatomy  of,  29 
Digital    examination    of    diseases    of 

rectum  and  anus,  897 
Dilatation,  atonic,  of  stomach,  treat- 
ment of,  410 
from  pyloric  spasm,  treatment  of, 

406 
gastric,  complications  and  conse- 
quences of,  394 
of  stomach,  setiology  of,  388 
of  stomach,  cured  by  intragastric 

electricity,  327 
of  stomach,  diagnosis  of  cancer 

from,  627 
of  stomach,  diagnosis  of,  396 
of  stomach,  differential  diagnosis 

of,  402 
of  stomach,  lavage  for,  313 
of  stomach,  prognosis  of,  405 
of  stomach,  treatment  of,  405 
relative  importance  of  atony  and, 

379 
Dilated    stomach,    its    surgical    treat- 
ment,   975 
Dilator,  Kelly's,  921 
Dinner,  test,  118 
Dioxy-diamido-arseno-benzol      ( Ehr- 

lich's  "606"),  for  syphilis,  584 
Diphtheritic  dysentery,  secondary,  799 
Directions     for    a    nutritive    enema, 

Ewald's,  249 
for  treating  membranous  catarrh 

of  the  intestines.    Von    Noor- 

den's,  816 
Discolorations   of  the   skin,   jaundice 

or  bronzing,  181 
Disease,  gastro-intestinal,  alkalies  in, 

348 
Reichmann's,  528 
Diseased  stomachs  need  rest,  205 


Diseases,  classification  of,  372 

classification   of,   with   regard   to 

dietetic  treatment,  216 
functional,  372,  373 
gastro-intestinal,  the  blood  in,  173 
of  rectum  and  anus,  892 
of  rectum  and  colon,  carbon  di- 
oxide in,  296 
of  stomach  and  intestines  not  al- 
ways separable,  ^il^ 
of    stomach,    place    of    HCl    in 
treatment  of,  332 
Displaced    organs,    tumors    external, 
etc.,   as   causes   of  obstruction, 
689, 
Displacements,  abdominal,    as   causes 
of     pelvic  disease,  462 
and  distortions  of  the   stomach, 

429 
lateral,  of  stomach,  frequent,  429 
of  abdominal  viscera,  460 
of  intestines,  treatment  of,  459 
of  the  liver,  456 

of  stomach   often  result  of  cor- 
set, 429 
of  stomach,  colon,  etc.,  reports  of 

cases  of,  464 
strapping  abdomen  for,  423 
visceral,    importance    of    correct- 
ing, 428 ;  effect  upon  blood,  954 
of  the  small  intestine,  457 
some  statistics  of,  460 
Distortions  of  stomach  from  cancer, 

607 
Diverticulum,-  Meckel's,   intussuscep- 
tion of,  676 
Dorkin's  results  from  long-continued 

rectal  feeding,  552 
Dosage  of  alkalies,  348,  349 
Doses,    minute,   modus    operandi    of, 

minute,  of  certain  drugs,  z^y 
Douche,  intragastric,  318 
Doumer's  application  of  galvanism  in 

chronic  intestinal  catarrh,  726 
Downward  displacement  of  liver  and 

intestines,  illustration  of,  458 


lOIO 


INDEX 


Drinking,  hygiene  of,  194 

Drinkers   and   smokers,    difficulty   of 

passing  stomach  tube  in,  11 1 
Dropsy  a  late  development  of  gastric 

cancer,  607 
Drug  treatment  for  nervous  dyspep- 
sia, 877 
Drugs,  usefulness  of,  in  minute  doses, 

366 
Dunin  on  central  anomalies  in  nerv- 
ous system,  as  causes  of  consti- 
pation, yd"} 
Duodenal  ulcer,  559 

ulcer,  jaundice  in,  561 
ulcer,  surgical  treatment  of,  975 
ulcer,  symptoms  of,  560 
Duodenum,  anatomy  of,  41 

diagnosis  of  round  ulcer  of,  562 
prognosis  of  round  ulcer  of,  564 
round  ulcer  of,  aetiology  and  pa- 
thology, 559 
round  ulcer  of,  complications  and 

sequels  of,  563 
ulcer  of,  diagnosis  from  ulcer  of 
stomach,  545 
Dynamic    obstruction     of    intestines, 

symptoms  of,  670 
Dysentery,  793 

aetiology  of,  793 
amoebic,  complications  of,  804 
amoebic,  aetiology  of,  803 
amoebic,  diagnosis  of,  804 
amoebic,  pathology  of,  803 
amoebic,  prognosis  of,  805 
amoebic,  quinine  enemas  for,  805 
amoebic,  symptoms  of,  804 
amoebic,  treatment  of,  805 
bacillary,  aetiology  of,  798 
bacillary,    complications   and    se- 
quels of,  799 
bacillary,  diagnosis  of,  799 
bacillary,  definition  of,  798 
bacillary,  ipecac  treatment  of,  800 
bacillary,  Shiga's  goat  serum  for, 

802 
bacillary,  pathology  of,  794 
bacillary,  symptoms  of,  799 


Dysentery,   bacillary,   tendency   of  to 
relapse,  800 
bacillary,  treatment  of,  800 
catarrhal,  aetiology  of,  794 
catarrhal  diagnosis  of,  796 
catarrhal,  pathology  of,  794 
catarrhal,  prognosis  of,  796 
catarrhal,    symptoms   of,    795 
catarrhal,  treatment  of,  796 
catarrhal,  milk  diet  in,  797 
chronic,  complications  of,  806 
chronic,  diagnosis  of,  806 
chronic,  pathology  of,  805 
chronic,  prognosis  of,  806 
chronic,  symptoms  of,  805 
chronic,  treatment  of,  806 
chronic,  small  doses  of  mercuric 

chloride  for,  807 
definition  of,  793 
diphtheritic,  secondary,  799 
Epsom  or  Rochelle  salt  in,  797 
forms  of,  794 
Dyspepsia,  diagnosis  of  nervous,  874 
nervous,  871 

nervous,  constipation  in,  878 
nervous,  diagnosis  of,  874 
nervous,  diagnosis  of,  from  gas- 
tric catarrh,  875 
nervous,      diagnosis      of,      from 
hyperchlorhydria,  anacidity,  or 
hypochlorhydria,  875 
nervous,      drug     treatment     for, 

877 
nervous,  electricity  for,  877 
nervous,  prognosis  of,  876 
nervous,  symptomatology  of,  872 
nervous,   treatment   of,   876 
prognosis  of  nervous,   876 
symptomatology  of  nervous,  872 
treatment  of  nervous,  876 


Early    diagnosis,   importance    of,    in 

gastro-intestinal  cancers,  639 
Eating,  excessive,  cause  of  acid  gas- 
tritis, 515 
hygiene  of,  194 


INDEX 


lOII 


Eating,  regularity  in  times  of,  essen- 
tial, 214 
Ebstein's  views  regarding  relaxation 

of  the  pylorus,  868 
Edebohls'  view  as  to  movable  kidney 
and  enteroptosis,  463 
on  aetiology  of  appendicitis,  739 
Efifect   of  alkalies  given   before   and 
after  meals;  349 
of    intragastric    electricity    upon 
secretion,  324 
Effervescent    test,     further    develop- 
ment of  Benedict's,  132 
Eggs    of    Uncinaria    Americana,    944 

in  treatment  of  gastritis,  497 
Ehrlich's  "  606 "  for  syphilis,  584 
Einhorn's  bead  test,  134 

electrode,     Reed's     modification, 

323 
gastrodiaphane,  86 
intragastric  spray  apparatus,  319 
statistics  of  movable  kidney,  419 
Electric  gastroscope,  88 
Electricity,  278 

efifect  of  intragastric,  upon  secre- 
tion, 324 
faradic   (induced  current),  280 
for  regurgitation  and  rumination, 

867 
for  nervous  dyspepsia,  877 
in  acid  gastritis,  methods  of  ap- 
plying, 521 
in  chronic  asthenic  gastritis,  501 
in  nervous  vomiting,  862 
intragastric,  409 
intragastric,     for    acid    gastritis, 

520 

intragastric,  for  stubborn  case  of 

acid  gastritis,  520 
intragastric,  in  gastric  fermenta- 
tion, 826 
intragastrically,  technique  of  ap- 
plying, 329 
static,  280 
Electrode,  Reed's  modification  of  the 

Einhorn,  323 
Electrodes,  intragastric,  322 


Electrodes,       for       zinc-and-mercury 
cataphoresis    in    rectal    opera- 
tions, 929 
Elimination  and  rest  in  treatment  of 

acute  enteritis,  711 
Elongation   and   displacement  of  the 

sigmoid  flexure,  447 
Emaciation,  182 
Embolism  or  thrombosis,  obstruction 

of  intestines  from,  669 
Emminghaus  on  degenerative  changes 

in  splanchnics,  767 
Enema,  Boas'  formula  for  a  nutritive, 
250 
nutritive,    recommended    by 

Ewald,  552 
nutritive,  in  appendicitis,  746 
nutritive,  in  gastric  ulcer,  552 
oil,    technique    of   administering, 
302 
Enteralgia,  880 

Enteritis,  acute,  diagnosis  of,  710 
acute,  diet  in,  714 
acute,  laxatives  for,  712 
acute,  pathology  of,  708 
acute,  prognosis  of,  711 
acute,  symptomatology  of,  709 
acute,  treatment  of,  711 
chronic,  from  cardiac  or  hepatic 

disease,  716 
chronic,   objective,   symptoms  of, 

719 
chronic,  varieties  of,  716 
hydro-electric  method  in   muco- 

membranous,  293 
treatment  of  colica  mucosa  in,  820 
Enteroliths,      obstruction     by     gall- 
stones, etc.,  691 
Enterospasm,  882 
Enzymes,  gastric,  56 
Epigastrium,  tenderness  on  pressure 

over,  187 
Epithelium,  in  feces,  167 
Erosions   of  stomach,   symptoms   of, 

557 
of  stomach,  treatment  of,  558 
Eructations,  182 


I0I2 


INDEX 


Eructations,       excessive,       antiseptic 
drugs  for,  827 
excessive,  intragastric  electricity 

for,  826 
nervous,  859 
Esophagus,  anatomy  of,  30 
Estimate  of  hemoglobin,  177 
Ewald  breakfast,  117 

Prof.   Dr.   C.   A.,   early   recogni- 
tion of  anacidity  of  the  stom- 
ach by,  833 
Ewald's    clinic,    experiments    carried 
out  by  the  author  in,  93 
directions  for  a  nutritive  enema, 

249 
opinion    of   pyloric    insufificiency, 

868 
test  breakfast,  117 
view  as  to  sympathetic  gastritis, 

479 
Exaggerated   and    displaced    sigmoid 
loop,  illustration  of,  449 

V-shaped    course    of    transverse 
colon,  451 
Examination    of   abdominal   muscles, 
78 

of  blood,  technique  of,  176 

of  blood  not  conclusive  in  stom- 
ach cases,  173 

of  feces,  162 

of  feces,  macroscopic,  163 

for  hemin  crystals,  599 

macroscopic,  of  stomach  contents, 
121 

microscopic,  of  feces,  166 

microscopic,  of  stomach  contents, 
141 

of  abdominal  muscles,  78 

of  the  spine,  how  made,  by  Ham- 
mond, 82 

partial,  of  urine  better  than  none, 
148 

physical,  of  the  patient,  T:}, 

of  stomach,  best  made  when  emp- 
ty, 95 
Excess  of  organic  acids,  531 
Excessive  appetite,  845 


Excessive  appetite   (bulimia),  180 
secretion  of  HCl,  effects  of,  57 
Excitability,  undue,  182 
Exercise    and    rest,    arrangement    of 
meals  with  relation  to,  211 
especially  of  trunk  muscles,  192 
in  chronic  enteritis,  726 
indispensable,  259 
passive,  268 
various  kinds  of,  260 
Exercises,  gymnastic,  in  gastric  cases, 

412 
Experiments  as  to   the  proper   food 
ration,  847 
carried    out    by    the    author    in 

Ewald's  clinic,  93 
concerning     food     requirements, 

199 
series  of,  with  digestants,  334 
with  sweet  foods,  227 
Expression  of  stomach  contents  con- 
demned, 120 
External  method  of  testing  for  gas- 
tric acidity,  132 
methods,  a  combination  of,  91 
tumors     and     displaced     organs, 
causes  of  obstruction,  689 
Extracting   sample   of   stomach    con- 
tents, 108 
Eyestrain  a  probable  cause  of  chronic 
sthenic  gastritis,  505 
as  cause  of  gastro-intestinal  neu- 
roses, 826 


Paradic  currents,  action  of,  on  gas- 
tric secretion  discovered,  326, 412 

Fasting,    for  chronic  catarrh  of  the 
intestines,  722 
indications      and      contra-indica- 
tions  for,  209,  752 

Fat  in  feces,  167 

Fattening  as  a  remedy  for  movable 
kidney,  426 

Fatty  acids,  quantitative  test  for,  140 

Fecal  impaction,  903 
segregators,  164 


INDEX 


lOI 


Feces,  chemical  reaction  of,  in  enteri- 
tis,   710 
examination  of,    162 
hardened,  obturation  by,  a  cause 

of  bowel  obstruction,  673 
illustrations  of  microscopic  find- 
ings in,   172 
in   health,    162 
in  stomach  contents,  123 
microscopic  examination  of,   166 
Feeding    by    other    routes    than    the 

mouth,  248 
Femoral  hernia,  684 
Fermentation,   antis-eptic    drugs    for, 
827 
from     chronic     gastric     catarrh, 

treatment  of,  826 
hydrochloric  acid  does  not  pre- 
vent, 334 
Ferruginous  mineral  waters,  357 
Fetor    of    breath,    or    foul    taste    in 

mouth,  179 
Fever     and     chills     in     appendicitis, 

72,2, 
in  acute  catarrh  of  intestines,  710 
Fibers,  muscle  in   feces,   167 
Fibrosis   in   gastric   catarrh,   illustra- 
tion of,  491 
Finsen  light  treatment,  309 
Fissure  of  the  anus,  909 
Fistula  in  ano,  914 
gastrocolic,   607 
gastrocolic,  setiology  of,  607 
gastrocolic,  symptoms  of,  607 
Fistulas,   a   majority   non-tubercular, 

916 
Flatulency,  chronic  appendicitis  as  a 
source  of,  824 
excessive,  a  result  of  numerous 
different    gastro-intestinal    dis- 
orders, 823 
gastric  or  intestinal,  182 
its  reflex  influence  upon  the  sex- 
ual   organs,   964 
treatment  of,  826 
Flexner's  bacillus  as  a  cause  of  dys- 
entery,   794,   808 


Fletcher,  on  buccal  reflex,  846 
Flexure,  intestinal,  surgical  treatment 

of,   997 
Flies  as  cause  of   dysentery,  793 
Fluidity  of  stomach  contents,  123 
Flushing  the  colon,   301 
Folin-Hopkins   method   of  determin- 
ing  the    amount   of   uric   acid, 
154 
Food  articles,  proportions  of  the  sev- 
eral  ingredients   in,   209 
accessories,  and  alcohol,  195 
definition  of,  193 
injection  of,  subcutaneously,  251 
requirements,  recent  experiments 

concerning,    199 
requirements      under      different 
conditions,  199 
Foods,  classification  of,  197 
Foreign     bodies     in     the     stomach, 
619 
bodies,     obturation     by,     as     a 
cause     of    bowel     obstruction, 

673 

Forms  of  appendicitis,  728 
of  chronic  gastritis,  485 
of  intestinal  ulceration,  585 
of  micro-organisms  in  the  gastro- 
intestinal  tract,  932 
of     treatment,     mechanical,      in 
chronic  gastritis,  499 

Formula,  Boas',  for  a  nutritive  ene- 
ma, 250 

Formulas  for  acute  enteritis,  713 

Forward  and  backward  body  bend- 
ing, illustration  of,  264 

Foul  taste  in  mouth,  179 

Free  HCl  often  present  in  tubercu- 
losis,   956 

Frequency    and   incidence    of    cancer 
of  the  stomach,  602 

Freund  and  Topfer's  test  for  urinary 
acidities,  156 

Fruits,  the  more  acid,  objectionable 
in  acid  gastritis,  517 

Further  development  of  the  Benedict 
effervescent  test,  132 


IOI4 


INDEX 


Gall-stones,  obturation  by,  as  a  cause 

of  intestinal  obstruction,  672 
Galvanism  for  chronic  intestinal  ca- 
tarrh, 726 
(continuous  current),  278 
in  acid  gastritis,  521 
in  treatment  of  gastralgia,  839 
Gangrene  in   strangulation  ileus,  687 
Gas,   belched,   often   from  the   intes- 
tines, 823 
Gastralgia,  aetiology    and    symptoms 

of,  836 
Gastrectasis,  acute,  387 
lavage  for,  313 
pronounced,    466 
Gastric   acidity,   external   method   of 
testing  for,   132 
atony,   378 

cancer,       differential       diagnosis 
from  other  abdominal  tumors, 
628 
cancer,  hemorrhage  from,   616 
cancer,  histologic  changes  in,  623 
cancer,  indications  for  an  explo- 
ratory incision  in,  640 
cancer,    operative    treatment    of, 

641 
carcinoma,    symptomatology     of, 

609 
cases    secondary  to  Bright's  dis- 
ease, 413 
cases  secondary  to  heart  disease, 

413 
catarrh,  acid,  aetiology  of,  504 
catarrh,  acid,  diagnosis  of,  509 
catarrh,  acid,  symptoms  of,  506 
catarrh,    acid,    microscopic    help 

in,  512 
catarrh,   acid,   pathology   of,    505 
catarrh,    chronic,    beverages    al- 
lowed in,  498 
catarrh,    chronic,    prognosis    of, 

495 
catarrh,    chronic,     treatment     of, 

dietetic  and  hygienic,  496 
catarrh,     diagnosis     of    nervous 

dyspepsia  from,  875 


Gastric    catarrh,    fatty    degeneration 
of   the   glands,   illustration   of, 
489 
digestion,  55 

dilatation,  complications  and  con- 
sequences  of,    394 
enzymes,  56 
flatulency,,  182 
glands,  anatomy  of,  36 
glands,  best   stimulant   for,   HCl, 

355 
hemorrhages,      source      of      the 

larger,  596 
hypergesthesia,  most    frequent  in 

hyperchlorhydria,  840 
hypersesthesia,     Riegel's     defini- 
tion  of,   841 
Inflammations,  pathology  of,  471 
juice,  normal  percentage  of  HCl 

in,  56 
motility,  salol  test  of,  104 
motility,    simple   tests  for,   383 
motor  power,  determination,  98 
motor  function,  author's  method 

of   determining    state   of,   90 
muscles,    modes    of    stimulating, 

SOI 
neuroses,  secretory  and    sensory, 

830 
phlegmon,  diagnosis  of,  483 
phlegmon,  symptoms  of,  482 
phlegmon,  treatment  of,  483 
surgery,    986 
tetany,  treatment  of,  413 
ulcei-,    complications   of,    540 
ulcer,  curative  treatment  of,  551 
ulcer,  diagnosis  of,    from  Reich- 

mann's  disease,  529 
ulcer,  diet  in,  551 
ulcer,   differential   diagnosis,   546 
ulcer,  hemorrhage  of  the  stomach 

in,  544 
ulcer,   massage  in,   554 
ulcer,    medicinal     treatment    in, 

554 
ulcer,  nutritive  enemas  in,  552    . 
ulcer,  pathology  of,  535 


INDEX 


Gastric  ulcer,  prophylactic  treatment 
of,  549 

ulcer,  sequels  of,  541 

ulcer,   surgery   of,   986 

ulcer,  symptomatology  of,  536 

ulcer,   syphilitic,   580 

ulcer,  treatment  of  complications 
and  sequels  of,  556 
Gastritis  acida,  485 

acid,  and  HCl  excess,  diet  in,  515 

acid,  and  HCl  excess,  medicinal 
treatment   in,    522 

acid,  and  HCl  excess,  treatment 
of,  514 

acid,  quantitative  analyses  neces- 
sary to  diagnosis  of,  514 

acute  and  subacute,  471 

acute,  diagnosis  of,  473 

acute,  report  of  case  of,  474 

acute,  symptoms  of,  473 

acute,  treatment  of,  474 

alcoholic,    early    resumption    of 
feeding  in,  481 

chronic,  different  forms  of,  485 

chronic,  difficulty  of  diagnosing, 

494 
chronic,  diagnosis  of,  492 
chronic  hypertrophic,  486 
chronic,     Homburg,     Kissingen, 

and  Wiesbaden  waters  for,  500 
chronic,     lavage      most      useful 

remedy  for,  499 
chronic,  sthenic,  504 
chronic,   syphilitic,   579 
chronic,  symptomatology  of,  489 
complicating  carcinoma,  647 
fibrinous,  483 
mycotic,  483 

infectious  and  parasitic,  483 
mucous,  486 

in  general,  pathology  of,  488 
polyposa,  489 

purulent  or  phlegmonous,  482 
septic,  from  oral  sepsis,  825 
simple  acute,  472 
subacute,  477 
sympathetic,  479 


IO15 

Gastritis,  toxic,  479 

toxic,  necessity  of  emptying  the 

stomach  in,  481 
toxic,  treatment  of,  481 
Gastrocolic    fistula,    aetiology   of,   607 

fistula,  symptoms  of,  607 
Gastrodiaphane,   Einhorn's,  86 
Gastro-intestinal   affections,   uranaly- 
sis  indispensable  in,  143 
cancers,  early  diagnosis  most  im- 
portant, 639 
disease,  alkalies  in,  348 
disease,   dietetic  faults  the  most 

frequent  cause  of,  207 
diseases,  the  blood  in,  173 
diseases,   their  relation  to  other 

diseases,  953 
functions  in  relation  to  tubercu- 
losis,   955 
neurasthenia,  871 
tract,  bacteria  and  animal  para- 
sites in,  931 
Gastroptosis,  aetiology  of,  430 
surgical    treatment   of,   990 
symptomatology  of,  432 
treatment  of,  434 
Gastroscope,   electric,   88 
Gastrospasm,  851 

Gastrosuccorrhea   chronica   continua, 
symptoms  of,  528 
chronica  periodica,  symptoms  of, 
528 
Gastroxynsis,  symptoms  of,  530 

treatment  of,  530 
Gavage  in  anorexia,  849 
General    massage   for    acid   gastritis, 

522 
Genital   organs,   relation   of  diseases 
of,  to  gastro-intestinal  diseases, 

963 
Glands,  cardiac,  from  a  dog's  stom- 
ach, 34 
and    lymphoid    tissue    from    ap- 
pendix, 42 
from  colon  and  goblet  cells,  43 
from  cardiac  end  of  the  stomach, 
35 


ioi6 


INDEX 


Glands   from  pyloric  end  of  stomach, 
36 
gastric,  anatomy  of,  zl 
pyloric,  from  a  dog's  stomach,  34 

Glenard  on  displacements  as  causes 
of  constipation,  767 

Glenard's  disease,  415 

Glenard's  theory  as  to  cause  of  dis- 
placements of  stomach,  430 

Glycerophosphates  and  hypophos- 
phites    in    nervous    dyspepsia, 

354 

Goblet  cells  and  glands  from  the 
colon,   43 

Gould,  Dr.  George  M.,  views  of,  re- 
garding ocular  faults  as  causes 
of  neuroses,  826 

Gradual  dilatation  for  stricture  of 
the  rectum,  921 

Gymnastic  exercises  in  gastric  cases, 
412 

Gymnastics,  special  forms  of,  recom- 
mended, 262 
rowing,   etc.,   for  abdominal   dis- 
placements, 459 

Gyromele,   Turck's,  87 


Hair  balls  in  the  stomach,  619 
Hardened  feces  a  cause  of  intestinal 

obstruction,  673 
Hay's  test   for  the  bile  acids,    157 
Headache,  183 
Health,  feces  in,  162 
Heart  disease,  in  relation  to  gastro- 
intestinal  affections,    965 
enlarged  by  digestive  faults,  966 
Heat  and  cold,  as  remedies,   309 
Hematemesis  from  other  causes  than 
ulcer,  544 
less  frequent  causes  of,  597 
in  carcinoma,  648 
Hemin  crystals,  examination  for,  599 
Hemoglobin,  to  estimate  the,   177 
Hemorrhage  from  gastric  cancer,  616 
from     perforation     of     duodenal 
ulcer,  56s 


Hemorrhage  from  stomach  and  intes- 
tines, diagnosis  of,   598 

from  stomach  and  intestines, 
symptoms  of,  598 

from  stomach  and  intestines, 
treatment  of,  600 

from    stomach    in    gastric    ulcer, 

544 

from  stomach,  most  important 
symptom  of  ulcer,  544 

gastric,  source  of  the  larger,  596 

in  gastric  ulcer,  540 

or  loss  of  blood  or  altered  blood 
by  mouth  or  rectum,  183 
Hemorrhoids,  capillary,  905 

fibrous,  90s 

internal,  905 

thrombotic,  90S 

varicose,  90S 

varieties  of,  904 
Henry's  observations  concerning  the 

blood  in  gastric  cancer,   174 
Hepatoptosis,  456 
Hernia,  diaphragmatic,  684 

femoral,  684 

inguinal,  684 

intestinal  obstruction  by,  684 

inverted  position  for,  688 

obturator,  68s 

retroperitoneal,   684 

sacrosciatic,   685 

taxis   in,  688,   997 

through  slits  in  mesentery,  684 

umbilical,  684 
Herschell-Dean    triphase    apparatus, 

illustration  of,  284 
High-frequency  currents,  283 
Histologic  changes  in  gastric  cancer, 

623 
History,  importance  of  a  full,  6s 
Homburg  and  Kissingen  waters,  351 

Kissingen  and  Wiesbaden  waters 
in  chronic  .gastritis,  500 
Hookworm  disease,  eosinophilia  in,  178 
Horseback  riding,  261 
Hot-water    cure,    meat    and,    in    ca- 
tarrhal conditions,  221 


INDEX 


IOI7 


Hour-glass  contraction,  436 

contraction   of  the  stomach,  607 
stomach    as    a   result    of   gastric 

ulcer,  542 
stomach,     diagnostic     signs     of, 

542 
stomach,  treatment  of,  989 
Hydriatic  procedures,  309 
Hydrochloric  acid,  absence  of,  not  a 

proof  of  cancer.  612 
an  injurious    remedy    in    certain 

cases.  333 
best    stimulant    for    the    gastric 

glands,  355 
cases  showing  use  of,  338-341 
does  not    prevent    fermentation, 

334 
and  bitter  tonics,  good  remedies 

for  anorexia,  849 
effects  of  excessive  secretion  of, 

57 

excess,  meats  in,  218 

for  eructations  with  deficient  se- 
cretion, 827 

later  experience  with,  342 

place  of,  in  the  treatment  of  gas- 
tric diseases,  332 

secretion,    relation    between    uri- 
nary acidity  and,  144 

stimulating    effects    upon    secre- 
tion, 343 

secretion   increased   by   massage, 
270 

secretion,     what     constitutes     a 
normal,  510 

simpler  tests  for,  126 

valuable  effects  of,  335 
Hydro-electric        applications        for 
chronic  intestinal  catarrh,   727 

applications     within    the    bowel, 
288 

method      in      muco-membranous 
enteritis,  293 

method,    prerequisites    for,    and 
limitations  of,  294 
Hygiene  of  eating  and  drinking,  194 

personal,  192 


Hygienic  and   climatic  measures    in 
tubercular    ulcerations    of    the 
gastro-intestinal  tract,  575 
and  dietetic  treatment  of  chronic 
gastric   catarrh,   496 
Hypersesthesia,  gastric,  840 
Hypertrophic  stenosis  of  the  pylorus, 

620 
Hyperassthesia,   gastric,    as    cause   of 
motor    neuroses     of     stomach, 
830 
Hyperchlorhydria,  a  cause  of  excess- 
ive appetite,  846 
case  of,  aggravated  by  massage, 

271 
as  cause   of   motor   neuroses   of 

stomach,  830 
medicinal  remedies  in,  531 
mistaken      for     hypochlorhydria, 

832 
oxygen     peroxide,      an     efficient 

remedy   for,   524,   531 
prognosis  of,  530 
symptomatology  of,  527 
tendency    to,    among    intellectual 

people,  215 
treatment  of,  525 
Hypnotic  drugs,  harmfulness  of,  194 
Hypnotics     in    gastro-intestinal     dis- 
eases, 356 
Hypochlorhydria,    nervous,    831 
Hypochondriac  region,  pain  referred 
to,  185 


Ileocecal  intussusception,  675 
Ileocolic  intussusception,  674 

and  ileocecal  intussusception,  675 
Ileus,  acute,  differential  diagnosis  of, 

693 
obturation,  relatively  good  prog- 
nosis in,  699 
obturation,  symptoms  of,  692 
prognosis   of  acute,  697 
strangulation,  symptoms  of,  685 
strangulation,   treatment   of,   688 
symptoms  of,  670 


ioi8 


INDEX 


Illustration  of  mechanical  vibrator, 
306 

Illustrations  of  microscopic  findings 
in  feces,  172 

Incidence  of  gastric  ulcers  in  differ- 
ent parts  of  stomach,  536 

Incision,  indications  for  an  explora- 
tory, in  gastric  cancer,  640 

Indican,      approximate      quantitative 
test  for,   151 
quick  test  for,  150 

Indications  for  lavage,  313 

for  massage  of  the  abdomen,  273 
for  treatment  in  carcinoma,  645 

Induced  current  (faradic  electricity), 
280 

Induction  of  premature  labor  in  per- 
nicious vomiting  of  pregnancy, 
864 

Infection  of  alimentary  tract  from 
mouth,  nose,  and  throat,  825 

Infectious  and  parasitic  gastritis,  483 

Inflammations,  gastric,  pathology  of, 

471 

Inflation  of  stomach  and  colon,  99 

Inguinal  hernia,  684 

Injected  intestine,  showing  central 
lacteal  and  arrangement  of  ca- 
pillaries in  villus,  41 

Injection  treatment  of  hemorrhoids, 
907 

Impaction,  fecal,  903 

Insomnia,  neurasthenia,  etc.,  relation 
of,    to    gastro-intestinal    affec- 
tions,  962 
produced  by  disease  of  stomach 
or  bowels,  relief  of,  355 

Inspection  of  abdomen,  74 
of  anus,  896 
thorough,  importance  of,   196 

Instrumental  tests  in  diagnosing  gas- 
tric dilatation,  400 

Instruments  for  determining  the  size 
and  position  of  the  viscera,  85 
required  in  rectal  work,  897 

Insufficiency,  motor  (mechanical),  of 
the  stomach,  378 


Insufficiency  of  cardia,  866 

of  pylorus,  868 
Internal  hemorrhoids,  905 
Interrogation  of  the  patient,  65 
Intestinal  antiseptics,  935,  936 

canal,  anatomy  of,  41 

catarrh,     chronic,     diagnosis'    of, 
720 

catarrh,    chronic,    pathology    of, 
716 

catarrh,    chronic,    prognosis    of, 
721 

catarrh,    chronic,     treatment     of, 
722 

catarrh,  purpetrol,  a  remedy  for, 
360 

colic,  882 

concretions,  obturation  by,  d^Z 

digestion,  57 

fermentation,  from  causes  in  ap- 
pendix, 826 

flatulency,  182 

flexure,     surgical     treatment     of, 

neurosis,  treatment   of,  888 
obstruction,   acute,   treatment  of, 

699 
obstruction  by  hernia,  684 
obstruction,    classification   of,  668 
obstructions  from  calculi,  worms, 

etc.,    995 
obstruction    generally,    668,    995 
obstruction,  pathology  of,  693 
surgery,    992 
tumors,    surgery   of,   994 
ulceration,  diagnosis  of,  590 
ulceration,  symptoms  of,  588 
ulceration,  treatment  of,  591 
ulceration,  various  forms  of,  585 
Intestine,  volvulus  of,  683 
Intestines,  aetiology  of  acute  catarrh 

of,  707 
anatomy  of,  41 
chronic     catarrh     of,     aetiology, 

715 
diagnosis  of  tubercular  ulcers  in, 

570 


INDEX 


IOI9 


Intestines,  displacements  of  small,  457 
gas  belched  from  the,  823 
hemorrhage  from   stomach    and, 

594 

membranous  catarrh  of,  aetiology 
of,  810 

membranous  catarrh  of,  after- 
treatment  of,  819 

membranous  catarrh  of,  diag- 
nosis of,  812 

membranous  catarrh  of,  pathol- 
ogy of,  812 

membranous  ^.atarrh  of,  prog- 
nosis of,  814 

membranous  catarrh  of,  symp- 
toms of,  811 

membranous  catarrh  of,  treat- 
ment of,  814 

neuroses  of,  879 

prognosis  of  tubercular  ulcers  in, 
572 

stenosis  of,  from  carcinoma,  657 

stomach  and,  diagnosis  of  hemor- 
rhage from,  598 

stomach  and,  diseases  of,  not  al- 
ways separable,  376 

stomach  and,  symptoms  of  hem- 
orrhage from,  598 

stomach  and,  treatment  of  hem- 
orrhage from,  600 

strangulation  by  knotting,  etc., 
685 

symptoms  of  displacements  of 
small,  459 

treatment  of  displacements  of, 
459 

treatment  of  syphilitic  disease  in, 
584 

treatment  of  tubercular  ulcers  in, 
572 

tubercular  ulcers  of,  567 

tumors  of,  course  and  complica- 
tions of,  660 

tumors  of.  diagnosis  of.  661 

tumors  of,  other  diagnostic 
points  in,  664 

tumors,  pathology  of,  653 


Intestines,  tumors  of,  prognosis  and 

treatment,  665 
tumors   of,    symptomatology    of, 

654 
Intragastric  douche  and  spray,  318 
electricity,  409 

electricity  a  remedy  for  excess- 
ive appetite,  846 
electricity,  administration  of,    as 

easy  as  lavage,  321 
electricity,   as   simple   as   lavage, 

321 
electricity  in   fermentation  from 

chronic  gastric   catarrh,  826 
electricity,  effect  of,  upon  secre- 
tion, 324 
electricity  for  acid  gastritis,  520 
electricity,  indications  for,  321 
electricity   in   fermentation   from 

deficient  gastric  motility,  826 
electrode  for  gastric  hypersesthe- 

sia,  842 
electrodes,   322 
faradization,  for  gastrectasis,  408, 

409 
faradization,    technique    of,    for 

acid  gastritis,  520 
Introducing  the  tube,  iii 
Intussusception  as  cause  of  intestinal 

obstruction,  672 
chronic,  701 

ileocolic  and  ileocecal,  675 
of  jejunum,  illustration  of,  673 
of   Meckel's   diverticulum,  676 
surgical   treatment   of,   996 
treatment   of,   682,   996 
treatment  of  colic  form  of,  683 
varieties  of,  ^'j6 
Invaginated    Meckel's     diverticulum, 

illustration  of,  677 
Iodoform  test  for  acetone,  Leiben's, 

159 
Iron   and   its   principal   preparations, 

356 
chloride  of,  as  an  antiseptic,  361 
test  for  blood,  599 
waters  of  the  United  States,  358 


^ 


I020 


INDEX 


Irritability  of  temper,  184 
Irritative  conditions,   diet  in,   217 
Irritable  throats,  training,  112 
Ischiorectal  abscess,  912 


Jaundice  in  duodenal  ulcer,  561 

or  discolorations  of  skin,  181 
Jones'   (Allen  A.)   contributions  con- 
cerning gastralgia  of  syphilitic 
origin,  582 
(Allen  A.),   observations   of,   as 
to    diarrhea    from    hypochlor- 
hydria,  708 
Juvenile  vomiting,  860 


Kelly,   A.   O.    J.,   on   origin   and   de- 
velopment      of       appendicitis, 
730 
Kelly's  dilator,  921 
Kidney  displaced  as  cause  of  intesti- 
nal obstruction,  689 
movable,  aetiology  of,  418 
movable,    as   cause   of   intestinal 

obstruction,  670 
movable,  diagnosis  of,  421 
movable,    dilated     stomach,    etc., 

467 
movable,  symptomatology  of,  419 
movable,  treatment  of,  423 
prognosis  of  movable,  422 
Kidneys,  diseases  of,  and  diabetes,  in 
relation  to  gastro-intestinal  af- 
fections, 968 
how  located  by  bimanual  palpa- 
tion, 79 
movable.  416 
Kissingen  and  Homburg  waters,  351 
Homburg  and  Wiesbaden  waters 
in  chronic  gastritis,  500 
Knife,  fistula,  Martin's,  916 
Klemperer's  statistics  as  to  the  motor 

function  in  tuberculosis,  961 
Knapp's  theory  of  the  pylorus,  868 
Knotting  of  the  intestines  by  stran- 
gulation, etc.,  68s 


Kussmaul-Fleiner  treatment  of  gas- 
tric ulcer,  555 
Kuttner  aspirator,  114 


Lack  of  appetite,  848 
Lactic  acid-free  meal,  118 

acid,  quantitative  test  for,   140 
acid,  test  for,  127 
Lane,  Arbuthnot,  on  displaced  kidney 

as  cause  of  constipation,  690 
Laparotomy,    immediate,    the    treat- 
ment of  volvulus,  684 
Later  experience  with  HCl,  342 
Lavage,  apparatus  for,  314 
best  time  for,  314 
compared  with  intragastric  elec- 
tric treatment,  321 
for  chronic  gastrectasis,  314 
for  gastrectasis,  313 
in  atonic  dilatation  of  the  stom- 
ach,  413 
in  the  treatment  of  fermentation, 

826 
indication  for,  313 
most  useful  of  curative  measures 

in  chronic  gastritis,  499 
of  stomach,  illustration  of,  316 
often  helpful  in  ileus,  700 
useful  in  sthenic  gastritis,  519 
Laxatives  and  purgatives  in  gastro- 
intestinal affections,  363 
Lenhartz   treatment    of    ulcer,    555 
Leube's  diet  scheme,  242 
Leucocytes  in  feces,  168 
Levico  iron  water,  358 
Liquors,  alcoholic,  effects  of,  230 

spirituous,   objectionable   in   acid 
gastritis,  518 
Liver,  anatomy  of,  45 

displacements  of,  456 
functions  of,  59 

the,  its  relation  to  gastro-intesti- 
nal affections,  963 
various  degrees  of  ptosis  of,  457 
Lower  edge  of  liver,  pain  referred  to, 
185 


INDEX 


I02I 


Lungs,  blood  from,  600 
Lymphadenoma,  619 
Lymphatics,  veins  and,  39 


Macroscopic   examination    of    feces, 
163 
examination  of  the  stomach  con- 
tents, 121 
Magnesium  phosphate-crystals  in  case- 

of   hyperchlorhydria,   527 
Magnetic  oxide   for  X-ray  work,  89 
Malignant  tumors  of  the  rectum,  925 
Management  of  appendicitis,  762 
Manual     replacement     of     prolapsed 
organs,  459 
therapy,    307 
Mapping  out  the  boundaries,  97 
Marginal  abscess  of  rectum.  912 
Martin's  conical  speculum,  898 

fistula   knife.   916 
Massage    and    Swedish    movements, 
268 
case    of    hyperchlorhydria     pro- 
duced by,  271 
general,  for  acid  gastritis,  522 
HCl  increased  by,  270 
in  gastric  ulcer,  554 
of  abdomen,  459 
of    abdomen,     contra-indications 

for,  274 
of  abdomen,  indications  for,  273 
of  abdomen,  valuable  in  chronic 

asthenic  gastritis,  501 
of  colon,  Turck's  method  of,  301 
Massey's  method  in  cancer  of  the  in- 
testines, 665 
method   in   malignant   rectal   tu- 
mors, 928 
Mastication,     insufficient,     cause      of 
acid  gastritis,  515 
thorough,  223 
Meals,  arrangement  of,  with  relation 
to  rest  and  exercise,  211 
effect   of   alkalies    given    before 
and  after,  350 
Measures  to  combat  possible  collapse 


from  sudden  emptying  of  the 

bowel,  291 
Meat    and    hot-water    cure    for    ca- 
tarrhal conditions,  221 
and      hot-water      treatment      of 

chronic  enteritis,  722 
diet   not  the  best    in    excessive 

HCl  cases,  515 
Meats  in  HCl  excess.  218 
Mechanical  forms  of  treatment,  499 
insufficiency  of  the  stomach,  378 
obstructions  as  cause  of  gastrec- 

tasis,  391 
obstruction  of  intestines,  670 
treatment    for    movable    kidney, 

427 
vibration,      advantages      claimed 

for,  30s 
vibration,    in    treatment    of   gas- 

tralgia,  839 
Meckel's  diverticulum,  a  cause  of  in- 
testinal strangulation,  surgical 

treatment,  997 
diverticulum,  intussusception    of, 

676 
diverticulum  invaginated  into  its 

own  lumen,  679 
diverticulum  invaginated  into  the 

ileum,  678 
Medicinal  and  palliative  treatment  of 

carcinoma,   and  other    tumors 

of  the  stomach,  644 
remedies  for  acute  gastritis,  476 
remedies     in     hyperchlorhydria, 

531 

treatment    in    acid   gastritis    and 
HCl  excess,  522 

treatment  in  gastric  ulcer,  554 

treatment  of  gastritis,  502 
Membranous    catarrh    of  the   intes- 
tines, causal  treatment  of,  815 

catarrh  of  the  intestines,  aetiology 
of,  810 

catarrh    of   the   intestines,    diag- 
nosis of,  812 

catarrh  of  the  intestines,  dietetic 
treatment  of,  815 


I022 


INDEX 


Membranous     catarrh    of    the    intes- 
tines, Ewald  on,  8io 

catarrh  of  the  intestines,  pathol- 
ogy of,  812 

catarrh  of  the  intestines,  prog- 
nosis of,  814 

catarrh  of  the  intestines,  rest 
treatment  for,  816 

catarrh  of  the  intestines,  slime 
masses  in,  813 

catarrh  of  the  intestines,  symp- 
tomatic treatment  of,  814 

catarrh  of  the  intestines,  symp- 
toms of,  811 

catarrh  of  the  intestines,  theories 
as  to  nature  of,  809 

catarrh  of  the  intestines,  treat- 
ment of.  814 

catarrh  of  the  intestines,  von 
Noorden's  after-treatment  of, 
819 

catarrh  of  the  intestines,  von 
Noorden's  treatment  of,  814 

catarrh      of    the    intestines,    von 
Noorden's    views     concerning, 
809 
Mental  depression,  182 

or  nervous  strain  in  chronic 
sthenic  gastritis,  505 

strain   to   be   avoided   in    sthenic 
gastritis.  518 
Merycism,  866 

Mesenteric  infarct  as  cause  of  intes- 
tinal obstruction,  672 
Metabolism,  faulty,  as  cause  of  heart 

disease,  955 
Metastases  in  gastric  cancer,  606 

of  intestinal  tumors,  653 
Meteorism,  tympanites,  or  flatulency, 

883 
Method,  external,  of  testing  fer  gas- 
tric acidity,  132 

hydro-electric,  in  enteritis.  294 

objectionable,  of  getting  the 
stomach  contents,  120 

radical  surgical,  in  appendicitis, 
743 


Method,    summary    of    the    author's, 
100 
Turck's,  of  doing  massage  of  the 

colon,  301 
von  Noorden's,  in  colica  mucosa, 
comments  on,  818 
Methods,  external,  a  combination  of, 
for  outlining  boundaries,  91 
of  testing  the  motility  of  stom- 
ach, 105 
therapeutic,  255 
Microgastria,   437 

Microscopic     examination     of    feces, 
166 
examination     of     stomach     con- 
tents, 141 
findings  in  feces,  illustrations  of, 

172 
help  in  acid  gastric  catarrh,   512 
Milk  as  an  article  of  diet  for  dyspep- 
sia, 22,2 
water,  etc.,  232 
Mineral  waters,  alkaline,  349 
waters,  ferruginous,  357 
Minute  anatomy  of  the  stomach,  37 
Modes   of   dress  productive   of   gas- 
tric atony,  382 
of   stimulating  the  gastric  mus- 
cles, 501 
INIodification    of    the    Einhorn    elec- 
trode. Reed's,  323 
Morphin    and    narcotics    in    nervous 
dyspepsia,  354 
with  atropine,  large  doses  often 
needed     for     intestinal     colic, 
889 
Morris,  Robert  T.,  paper  by,  on  In- 
testinal Fermentation,  825 
]\Iotility,  gastric,  salol  test  of,  104 
gastric,  simple  tests  for,  383 
methods  of  testing,  105 
Motor  function  of  stomach,  56 

function  of  stomach,  importance 
of    strengthening    in    phthisis, 
964 
insufficiency  of  stomach,  378 
neuroses  of  stomach,  851 


INDEX 


1023 


Motor    power    of    stomach,    capacity 

and,  103 
Mouth,  foul  taste  in,   179 

infectious  in  gastric  cases,  825 
nose  and  throat,  infection  from, 
82s 
Movable    kidney    predisposing    cause 
of  sthenic  gastritis,  505 
kidney,  etiology  of,  418 
kidney,   as  a   cause  of  intestinal 

obstruction,  6go 
kidney,   diagnosis   of,   421 
kidney,     dilated     stomach,     etc., 

467 
kidney,   fattening  a  remedy  for, 

426 
kidney,    how   palpated,    79 
kidney  (nephroptosis),  416 
kidney  often   a  cause  of  hyper- 

chlorhydria,  420 
kidney,  palpation  of,  illustration, 

422 
kidney,  prognosis  of,  422 
kidney,  rest  treatment  of,  427 
kidney,  symptomatology  of,  419 
kidney,  treatment  of,  423 
spleen,  457 
Movements,  bowel,  70 
Mucoid   and    cystic    degeneration    of 

gastric  mucosa,  487 
Muco-membranous    enteritis,    hydro- 
electric method  in,  293 
Murphy's    method    of    operating    in 
complicated    appendicitis,    748 
Muscle  fibers  in  feces,  167 
Muscles,    gastric,    modes    of    stimu- 
lating, SOI 
Musser's    treatment    of    hyperchlor- 
hydria    with    large     doses    of 
nux  vomica,   524 
Myxoneurosis     intestinalis     membra- 
nacea   (Ewald),  810 

Narcotics  for  acute  ileus,  700 
Natural    position     of    the     stomach, 
32 

Nausea,  843 


Nausea    and   vomiting,    not   common 
results     of     passing     stomach 
tube,  112 
in  chronic  asthenic  gastritis,  how 

best  controlled,  502 
or  vomiting,  184 
Nephritis,  autotoxic,  treated  by  elec- 
tro-static currents,  969 
Nephroptosis   (movable  kidney),  416 
Nerve  tonics,  354 
Nerves,  secretory,  47 

spinal,   course  and   direction   of, 

49 
spinal,  course  of,  50-51 
vaso-motor,  48 

vaso-motor,  points  of  emergence 
of,  51 
Nervous    anacidity    of    the    stomach, 

833 
and  reflex  vomiting,  859 
atony  of  the  stomach,  865 
depression,   182 

derangements,     relation     of,     to 
gastro-intestinal  affections,  962 
dyspepsia,  871 

dyspepsia,      attributed     to     eye- 
strain, 826 
dyspepsia,  constipation  in,  878 
dyspepsia,  diagnosis  of,  874 
dyspepsia,     drug    treatment    for, 

877      _ 

dyspepsia,   electricity  for,   877 

dyspepsia,  prognosis  of,  876 

dyspepsia,  remedies  for,  843 

dyspepsia,     symptomatology     of, 
872 

dyspepsia,  treatment  of,  876 

eructation.  859 

forms  of  diarrhea,  792 

hypochlorhydria,  831 

secretory  derangements  of  stom- 
ach, 830 
Neurasthenia,  gastro-intestinal,  871 

insomnia,     etc.,    relation     of,    to 
gastro-intestinal  affections,  962 
Neuroses    in    gastro-intestinal    affec- 
tions, 272 


I024 


INDEX 


Neuroses   of   digestive    system    from 
reflex  causes,  825 
of  the-  intestines,  879 
of  the  stomach,  motor,  851 
Nitrous    oxide,    the    preferred  .anaes- 
thetic in  divulsion  of  the  anal 
sphincter,  902 
Nori-operative    measures    for   gastric 

dilatation.  406 
Normal  diet  table,  198 

HCl   secretion,   author's  view   as 

to,  510 
percentage    of    HCl    in    gastric 
juice,   56 
Nose  and  nasopharynx,  harmfulness 
of  catarrh   of,   193 
throat,      and     mouth,     infection 
from,  825 
Nutritive  enema.  Boas'  formula  for, 
250 
enema,    Ewald's    directions    for, 

249 
enemas  in  gastric  ulcer,  552 


Obstruction  by  a  sharp  flexure,  672 
by   displaced   organs,   etc.,   treat- 
ment of,  691 
by  gall  stones,  573 
by   gall    stones,    enteroliths,    etc., 

691 
by  the  Murphy  button.  692 
from      displaced      organs,      etc., 

symptoms  of,  690 
from     external     tumors,     symp- 
toms of,  690 
from  external  tumors,  treatment 

of,  691 
hernial,   symptoms  of,  685 
intestinal,    acute,    treatment    of, 

699 
intestinal,  by  hernia,  684 
intestinal,    by    obturation    rarely 

complete  at  first,  695 
intestinal,  classification  of,  668 
intestinal,    diliferential    diagnosis 
Jjetwep.o  various  forms,  698 


Obstruction,       intestinal       generally, 

symptoms  of,  668 
intestinal,  pathology  of,  693 
mechanical,  of  intestines,  672,  995 
of  bowels  from  cancer,  661 
of    intestines    from    thrombosis, 

669 
of  the   cardia   in   gastric   cancer, 

606 
tubercular  ulcers  and  growths  as 

causes  of  chronic,  705 
Obturation   by   hardened   feces,   as   a 

cause     of    bowel     obstruction, 

673 

by  intestinal  concretions.  673 
by  polypi,  as  a  cause  of  intestinal 

obstruction,  673 
by  worms,  as  a  cause  of  intes- 
tinal obstruction,  673 
Obturator  hernia,  685 

ileus,   symptoms  of,  692 
Ochsner's  description  of  his  method 
in  appendicitis,  745 
plan,  or  surgico-starvation  meth- 
od in  appendicitis,  744 
statistics  in  appendicitis,  741,  750 
CEdema  of  lower  extremities  in  can- 
cer of  the  intestines,  661 
Oil  enemas,  technique  of  administer- 
ing, 302 
Oils,  bland,  360 

mineral,  for  constipation,  782 
Olive-oil    treatment    of    constipation, 

782 
Operation     of     divulsion     of     anal 

sphincter,  901 
Operative   treatment   of  gastric   can- 
cer,  641 
Opiates    and    narcotics    as    remedies 
in    gastro-intestinal    affections, 

355 
Oppression    or    weight    in    stomach, 

185 

Oral    cavity,    importance    of   inspect- 
ing, 75 

Organic  acids,  excess  of,  531 
acids,  tests  for,  128 


INDEX 


102: 


Outlining  the  stomach,  authors 
method  of,  90 

Ova  of  intestinal  parasites,  940 

Overdosing  and  overdoing  in  thera- 
peutics, 257 

Overeating,  danger  of,  195 

Oxyuris  vermicularis,  940 


Pain  and  insomnia  from  disease  of 
stomach   or   bowels,    relief   of, 

355 
in    carcinoma,    measures    to    re- 
lieve, 649 
referred  to  the  region  of   stom- 
ach, 185 
referred  to  the  right   hypochon- 
driac region  or  lower  edge  of 
liver,  185 
where  felt  in  strangulation  ileus, 
687 
Palliative  and  medicinal  treatment  of 
carcinoma  and  other  tumors  of 
stomach,  644 
for  bleeding  in  cases  of  hemor- 
rhoids, 909 
Pallor  of  skin,  185 
Palpation,  Tj 

of  appendix,  -739 

of    movable    kidney,    illustration 

of,  422 
over  the  spine,  81 
Pancreas,  anatomy  of,  46 
Pancreatic  preparations,  347 
Paralysis  of  intestines,  887 

of  intestines,  treatment  of,  890 
Parasites,  animal,  in  feces,  168 

intestinal,  eosinophilia  a  sign  of. 
178;    descriptions    of,    936 
Parasitic  gastritis,  infectious,  483 
Pathogenic  micro-organisms  in  feces, 

illustration  of,  169 
Pathology    and    aetiology    of    round 
ulcer  of  the  duodenum,  559 
of  acid  gastric  catarrh,  505 
of  acute  enteritis,  708 
of  amoebic  dysentery,  803 


Pathology  of  appendicitis,  730 
of  bacillary  dysentery,  798 
of  catarrhal  dysentery,  794 
of  cancer  of  stomach,  603 
of  chronic  dysentery,  805 
of    chronic    gastritis    in    general, 

488 
of  chronic  intestinal  catarrh,  716 
of  gastric  inflammations,  471 
of  gastric  ulcer,  535 
of    membranous    catarrh    of   the 

intestines,  812 
of  intestinal  obstruction,  693 
of  phlegmonous  or  purulent  gas- 
tritis, 482 
of  toxic  gastritis,  480 
of  tumors  of  the  intestines,  653 
of  tubercular  ulcers  of  the  stom- 
ach, 568 
Patient,  interrogation  of,  65 
physical  examination  of,  TZ 
preparation  of,  109 
Pawlow's  experiments  with   HCl  on 

dogs,  342 
Penzoldt,  diet  directions  of,  242 
Penzoldt's   diet    for   atonic   constipa- 
tion, 778 
diet  tables   for   gradual  training 
of  digestive  capacity,  244 
Pepsin  and  its  action,  56 
compounds,  useless,  347 
tests  for,  130 
Peptones,  tests  for,  131 
Percussion,  auscultation  and,  85 

in   diagnosing   gastric   dilatation, 

399-400 
note  before  and  after  drinking  a 
solution  of  soda,  133 
Perforation    of    intestines    from    ca- 
tarrhal ulcers,  586 
in  strangulation  ifeus,  687 
of  stomach  in  gastric  ulcer,  S40 
particularly  frequent  in  duodenal 
ulcer,  565 
Perigastric    adhesions,   987 
Perigastritis,   surgical  treatment,  975 
Periodic  vomiting,  860 


I026 


INDEX 


Peristaltic  restlessness,  857 

unrest  of  the  intestines,  885 
unrest    of    the    intestines,    treat- 
ment of,  890 
Pernicious      anaemia      from      septic 
mouth,  825 
vomiting  of  pregnancy,  863 
Personal  hygiene,  192 
Pharynx,  anatomy  of,  29 
Phlegmonous    or    purulent    gastritis, 
482 
or   purulent   gastritis,    pathology 
of,  482 
Phototherapy  (the  Finsen  light  treat- 
ment), 309 
Physical  examination  of  the  patient, 

signs  of  appendicitis,  736 

Physiology  of  digestion  and  absorp- 
tion, 54 

Pigments,  biliary,   156 

Pleximeter,  Reed's,  96 

Podophyllin,  value  of,  in  diarrhea, 
364,  366,  367 

Points  of  emergence  from  the  spine 
of    special    vaso-motor    nerves, 

51 

Poland  spring  water,  350 

Polypi  as  cause  of  intestinal  obstruc- 
tion, 673 

Polypi,  obturation  by.  as  a  cause  of 
bowel  obstruction,  673 

Pottenger's  new  method  of  outlin- 
ing  organs,    103 

Pregnancy,  pernicious  vomiting  of, 
863 

Preparation  of  the  patient,  109 

Preparations,  pancreatic,  347 

Prerequisites  for,  and  limitations  of, 
hydro-electric  method,  294 

Procedures,   hydriatic,   309 

Proctoscope,  pneumatic,  Tuttle's,  899 

Prolapse  of  the  rectum,  917 

Propeptone.  tests  for,  131 

Prophylactic  treatment  of  gastric 
ulcer,  549 

Prophylaxis,  191 


Proportions    of    different    foods    in 
normal  diet,  198 
of  several  ingredients  in  food  ar- 
ticles, 209 

Pruritus  ani,  910 

Psychic  conditions   a   cause  of  ano- 
rexia, 849 

Ptyalism,  or  salivation,  186 

Pulley   exercise   for   arm   and  trunk 
muscles,  illustration  of,  265 

Pulse,     the,     in     strangulation     ileus, 
687 

Purgatives   for   intestinal   colic,   889 

Purpetrol   in   constipation   and   intes- 
tinal  catarrh,    360 

Purulent    or    phlegmonous    gastritis, 
482 

Purulent    processes    in    the    mouth, 

75 

Pus  in  the  stomach  contents,  123 

Pylorectomy,   indications    for,  988 
mortality  rate  of,  988 

Pyloric  cancer,  614 

cramp,  pylorospasm,  855 
glands  from  a  dog's  stomach,  34 
glands  from  end  of  stomach,  36 
insufficiency,    symptoms   of,   869 
insufficiency,  treatment  of,  870 
obstruction  as  a  cause  of  dilata- 
tion of  the  stomach,  391 

Pylorus,     cicatricial    contraction    of, 
972 
congenital,  stenosis  of,  438 
hypertrophic  stenosis  of,  620 
insufficiency  of,  868 
spasm  of,  507 

stenosis  of,  in  gastric  ulcer,  541 
thickening  of,  619 


Quantitative    test,    approximate,    for 
indican,   151 
test  for  fatty  acids,  140 
test  for  lactic  acid,  140 
tests    of    stomach    contents,    the 
more  important,  135 
Questioning,  systematic,  6rj 


INDEX 


1027 


Radiographs  of  the  viscera,  102 
Radium,  X-rays,  etc.,  in  cancer  of  the 

stomach,  636 
Rapid  eating  a  predisposing  cause  of 

sthenic  gastritis,  505 
Ration,  proper  food,  847 
Rectal   alimentation   as   an   auxiliary 
to  other  feeding,  251 
alimentation,  technique  of,  248 
examination    and    treatment,    in- 
struments for,  897 
relations  of  constipation,  goi 
Rectum,  anatomy  of,  44 

and  anus,  diseases  of,  892 

benign  tumors  of,  923 

carbon    dioxide    in    diseases    of, 

296 
prolapse  of,  917 
ulceration  of,  922 
Red  blood  cells  in  feces,  168 
Reed's      electrode,      illustration      of, 

324 
modification  of  the  Einhorn  elec- 
trode, 323 
Reflex  causes  of  flatulency,  825 

vomiting,  859 
Regularity  in  times  of  eating  essen- 
tial, 214 
Regurgitation,  or  rumination,   186 

rumination,  etc.,  866 
Reichmann's  disease,  403 

disease    (continuous    hypersecre- 
tion), 528 
disease,  diagnosis  of,  529 
disease,  treatment  of,  530 
Relation  between  urinary  acidity  and 
HCl  secretion,  144 
of  gastro-intestinal  to  other  dis- 
eases, 953 
of  respiratory  aflfections  to  gas- 
tro-intestinal   diseases,    962 
Relative  importance  of  atony,  dilata- 
tion, etc.,  379 
Relief   of   pain   and    insomnia,    from 
disease  of  stomach  or  bowels, 
355 
Remedies,  antiseptic,  361 


Remedies,   medicinal,   for   acute   gas- 
tritis,  476 
medicinal,    in    hyperchlorhydria, 
531 
Rennet  ferment,  tests  for,   130 
Rennin  zymogen,  56 
Reports  of  cases  of  coloptosis,  444- 
453 
of     cases    of    displacements     of 

stomach,  colon,  etc.,  464 
of    cases    illustrating    abdominal 

displacements,  464-467 
of  cases  treated  by  HCl,  337 
of  two  cases  showing  effects  of 
intragastric  faradization,  326 
Resorcin    in    chronic    asthenic    gas- 
tritis, 502 
thymol,  etc.,  as  antiseptics,  362 
Respiratory  affections,  relations  of,  to 

gastro-intestinal  diseases,  962 
Rest  after  lavage,  318 

arrangement  of  meals  with  rela- 
tion to,  211 
cure,    the,    for    certain    cases    of 
chronic  intestinal  catarrh,  726 
essential  in  treatment  of  gastric 

dilatation,  409 
treatment,  276 
treatment  in  atonic  dilatation  of 

the  stomach,  411 
treatment,     special,     for     gastric 

ulcer,  554 
treatment    for    movable    kidney, 

427 
treatment  in  anorexia,  850 
Restlessness,  peristaltic,  857 
Results  must  decide  in  appendicitis, 

748 
Retroperitoneal  hernia,  684 
Rib,   floating  tenth,  419 
Richardson's  statistics  in  appendicitis, 
740,   741,   748 
view  as  to  time  for  operation,  754 
Riegel's  classification  of  nervous  and 
functional  diseases,  374 
definition     of    gastric     hyperses- 
thesia,  841 


1028 


INDEX 


Riegel's   view  as  to  hour-glass  con- 
traction, 437 
view  as  to  the  relation  of  chloro- 
sis  to   gastro-intestinal   condi- 
tions,  955 

Rigidity  over  right  rectus  muscle  in 
appendicitis,  T22, 

Rose's  apparatus  for  generating  car- 
bonic dioxide,  297 
carbon      dioxide      method      for 
chronic  intestinal  catarrh,  T2'j 
method     of     strapping    the     ab- 
domen for  displacements,  423 

Rosewater's  views  as  to  results  of 
enteroptosis,  420 

Rotary  movement  of  the  trunk 
while  sitting,  illustration  of, 
265 

Round  worms,  940 

Routes,  other,   for  feeding,  248 

Ruheman's   uricometer,    153 

Rumination,  or  regurgitation,  186 
regurgitation,  etc.,  866 

Sahli's  Dermoid  Test,  134 
Salicylates,  361 

Saline  laxatives   in  catarrhal   dysen- 
tery, 363 
laxatives  in  treatment  of  dysen- 
tery. 797 
Saline   waters,   von   Noorden's   book 
on  effects  of,  352 
or  chloride  waters,  351 
Salivary  digestion,  54 

digestion,  tests  for,  129 
Salivation,  or  ptyalism,   186 
Salol  test  of  gastric  motility,  104 
Sample    of    stomach    contents    easily 

obtained,  108 
Saratoga      Kissingen      and      Vichy 

waters,  350 
Sarcoma    and   benign    tumors,   treat- 
ment of,  650 
and     carcinoma     of     intestines, 

setiology  of,  652 
of    intestines,     differential    diag- 
nosis of,  from  cancer,  661 


Sarcoma  of  intestines   runs   a  more 
rapid  course  than  cancer,  661 
of  rectum,  930 
of  stomach,  616 

of   stomach,  setiology,  incidence, 
etc.,  of,  617 
Sarcinte  ventriculi,    141 
Schmidt's    test    of    proteid    digestion 

by  examination  of  feces,  134 
Scirrhus    of    gastric    walls,    diffuse, 

606 
Seat  worms,  940 
Secondary  diphtheritic  dysentery,  799 

intussusception  of  ileum,  679 
Secretion,  effect  of  intragastric  elec- 
tricity upon,  324 
excessive  in  stomach,  526 
HCl,    relation    between    urinary 
acidity  and,  144 
Secretory  derangements  of  the  stom- 
ach, nervous,  830 
nerves,  47 
Section     from     carcinoma     of     the 

pylorus,  illustration  of,  624 
Segregators,  fecal,  164 
Selection  of  stomach  tube,  109 
Sensory  disturbances  of  the  stomach, 

835 

Sequels  of  gastric  ulcer,  541 

Series    of   experiments    with    digest- 
ants,  345 

Sexual    excitement   harmful   in   acid 
gastritis,  519 

Sigmoid  flexure,  anatomy  of,  44 

loop  touching  left  kidney,  illus- 
tration of,  448 

Significance   of   blood   in   vomit   and 
stools.  595 
of  symptoms  in  diseases  of  rec- 
tum and  anus.  893 

Silver  nitrate  as  an  antiseptic,  361 
nitrate  combination  for  acid  gas- 
tritis. 524 
nitrate   in   chronic  asthenic  gas- 
tritis, 501 

Similarity     of     effects     of     different 
mechanical  methods,  310 


INDEX 


1029 


Simple  acute  gastritis,  472 

Simpler  tests  for  HCl,  126 

Skin,  pallor  of,  185 

Skirts  hung  from  waist,  harmfulness 
of,  469 

Sleeplessness,  remedies  for,  356 

Small  intestine,  displacements  of,  457 
intestines,  symptoms  of  displace- 
ments of,  459 

Smokers   and   drinkers,    difficulty   of 
passing  the  tube  in,  11 1 

Sodium  benzoate  as  an  antiseptic,  362 
bromide  as  a  remedy  in  gastro- 
intestinal afifections,  354 
bromide  with  tincture  of  chloride 
of     iron     in     gastro-intestinal 
afifections,  354 

Solids,  test  for  total  amount  of,  152 

Solution  of  soda,  percussion  note  be- 
fore and  after  drinking,  133 

Source  of  blood  found  in  the  stools, 

597 
of    the    larger     gastric    hemor- 
rhages, 596 
Spasm  of  cardia,  852 
»      of  entire  stomach,  851 

pyloric,  dilatation  from,  406 
of  pylorus,  507,  855 
Spastic      and      atonic      constipation, 
stools  in,  771 
constipation,     differential     diag- 
nosis between  atonic  and,  769 
constipation,  treatment  of,  781 
Special  forms  of  gymnastics  recom- 
mended, 262 
vaso-motor     nerves,     points     of 
emergence  of,  from  spine,  51 
Specimen  of  blood,  to  obtain  a,  175 
Speculum  vivalve,  Bodenhamer's,  898 

Martin's,   conical,  898 
Spices,  etc.,  drugs  not  foods,  229 
Spinal    irritation,    as    described    by 
Hammond,  81 
nerves,  course  of,  50-51 
Spine,  and  the  vaso-motor  nerves,  48 
points    of    emergence    from,    of 
special  vaso-motor  nerves,  51 


Spirits  of  chloroform  as  an  antisep- 
tic, 362 
Spirochsetas  in  syphilis,  578 
Spivak's  fecal  segregator,   165 
Splanchnoptosis,  415 
Splashing    sounds    in    abdomen  (suc- 
cussion),   186 
sounds  in  catarrh  of  cecum,  719 
sounds  in  intestines,  709 
sounds  in  stomach,  96 
Spleen,  movable,  457 
Spondylotherapy,  Abram's,  311 
Spray,  intragastric,  318 
Spraying  with  nitrate-of-silver  solu- 
tion for  gastric  hyperaesthesia, 
842 
Spring  waters,  alkaline  and  alkalies, 

in  hyperchlorhydria,  531 
Starch,  need  of  having  it  well  dex- 

trinized,  218 
Static  electricity,  280 

in  treatment  of  gastralgia,  840 
Statistics  of  displacements,  460 
Stenosis,    cicatricial,    of    the    cardiac 
opening  of  stomach,  987 
cicatricial,  of  the  pylorus,  988 
congenital,  of  pylorus,  438 
hypertrophic,  of  the  pylorus,  620 
of  intestines  from  carcinoma,  657 
of  pylorus  in  gastric  cancer,  606 
of  pylorus  in  gastric  ulcer,  541 
or    strictures    as    causes    of    in- 
testinal obstruction,  673 
symptoms  of  carcinomatous,  701 
Stiller's  sign,  floating  tenth  rib,  419 
Stimulants,  harmfulness  of,  197 
Stockton's  prescription  for  excessive 
HCl,  523 
views  regarding  gastric  syphilis, 

582 
acute  dilatation  of,  relations  of, 
to  surgery,  990 
Stomach,  anaiomy  of,  31 

and      iiuestines,      diagnosis      of 

neiiioirhage  from,  598 
and   mtestines,    diseases   of,    not 
always  separable,  376 


I030 


INDEX 


Stomach  and  intestines,  hemorrhage 
from,  594 

and  intestines,  symptoms  of 
hemorrhage  from,  598 

and  intestines,  syphilis  of,  578 

and  intestines,  treatment  of  syph- 
ihtic  disease  in,  584 

setio|ogy  of  atony  of,  381 

benign  tumors  of,  618 

blood  from,  and  from  lungs  or 
upper  air  passages,  600 

blood-vessels  of,  38 

cancer  of,  complications,  sequels, 
etc.,  606 

cancer  of,  frequency  and  inci- 
dence of,  602 

cancer  of,  pathology,  603 

cancer  of  the  body  of,  616 

cancer  of,  use  of  X-rays,  radium, 
etc.,  in,  636,  641,  642,  643 

cancer  of,  varieties  of,  603 

capacity  and  motor  power  of, 
103 

carcinoma  and  other  tumors  of, 
medicinal  and  palliative  treat- 
ment of,  644 

carcinoma  of,  dietetic  treatment 
of,  645 

carcinoma  of,  treatment  with 
X-rays,  etc.,  636-639 

carcinomatous  ulcer  of,  625 

chronic  dilatation  of,  388 

colon,  etc.,  reports  of  cases  of 
displacements  of,  464 

congenital  anomalies  of,  438 

contents,  bile,  blood,  feces,  or  pus 
in,  123 

contents,  expression  of  con- 
demned, 120 

contents,  fluidity  of,  123 

contents,  importance  of  examin- 
ing in  chronic  asthenic  gas- 
tritis, 493 

contents,  macroscopic  examina- 
tion of,  121 

contents,  microscopic  examina- 
tion of,  141 


Stomach    contents,    more    important 
quantitative  tests  of,  135 
contents,  objectionable  method  of 

getting,  120 
contents,    quantitative  -tests    of, 

135 
contents,  tests  of,  126 
diagnosis  of  atony  of,  383 
diagnosis  of  tubercular  ulcers  in, 

570 
diagnosis  of  ulcer  of,  from  ulcer 

of  the  duodenum,  545 
differential    diagnosis    of    dilata- 
tion of,  402 
dilatation,  prognosis  of,  405 
dilated,  illustration  of,  399 
dilated,  movable  kidney,  etc.,  467 
diseases    of,    place    of    HCl    in 

treatment  of,  332 
examination  of,  best  made  when 

empty,  95 
foreign   bodies   in,  991 
hemorrhage     from,     in     gastric 

ulcer,  544 
how    to    introduce    a    tube    into, 

most  easily,  108 
inflation  of,  99 
in    natural    position,    illustration 

of,  2,2 
methods   of   testing  the   motility 

of,  105 
nervous  atony  of,  865 
or  bowels,   relief  of  pain   or  in- 
somnia from  disease  of,  355 
pain  referred  to  region  of,  185 
prognosis  of  tubercular  ulcers  of, 

572 
sarcoma  of,   616,  989 
sarcoma   of,   setiology,  incidence, 

etc.,  of,  617 
symptomatology  of  atony  of,  382 
symptoms  and  diagnosis  of  sar- 
coma of,  617 
tests  of  the  capacity  of,  103 
treatment  of  dilatation  of,  405,  990 
treatment    of    tubercular    ulcers 
of,  572 


INDEX 


IO3I 


Stomach     tube,     how     to     determine 
when  passed  in  sufficiently  far, 

113 

tube,  selection  of,  109 

tube  sometimes  impracticable,  91 

tubercular    ulcers    of,    pathology 

of,  568 
ulcer  of,  aetiology  of,  533 
volvulus  of,  435 
washing  the,  downward,  500 
when  and  how  to  wash  out,  312 
Stomachs,  abnormally  small,  437 

diseased,  need  rest,  205 
Stools  always  small  in  organic  stric- 
ture of  bowel,  772 
and  vomit,  blood  in  both,  59 
and  vomit,  significance  of  blood 

in,  595 
in    atonic    and    spastic    constipa- 
tion, 771 
fetid,  in  diarrhea,  786 
may  be  variable  in  spastic  con- 
stipation, 771 
scybalous,  in  the  course  of  diar- 
rhea, 786 
source  of  blood  found  in,  597 
the,  in  chronic  enteritis,  720 
Strangulation  ileus,  symptoms  of,  685 
ileus,  treatment  of,  688 
of  the  intestines  by  knotting,  etc., 
685 
Strapping  the  abdomen,  423 
Strassburger's  fermentation  tube,  166 
Strengthening  the  abdomen  in  colop- 

tosis,  455 
Stricture  or  stenosis  as  cause  of  in- 
testinal obstruction,  673 
of  rectum,  919 
Strictures  from  carcinoma,  as  causes 
of  intestinal  obstruction,  674 
from   scars  of  ulcers,   as  causes 

of  bowel  obstruction,  673 
from    healed    ulcers    and    carci- 
noma  obstructing   the   bowels, 
701 
Structure  of  the  stomach  and  intes- 
tine, 44 


Subacidity,  nervous  gastric,  831 
Subacute  gastritis,  477 
Subphrenic  abscess,  541 
Succussion,    or    splashing   sounds    in 

abdomen,  186 
Sugar  in  chronic  gastritis,  497 

place  of,   most   difficult   point   in 
dietetics,  226 
Sulphates,  aromatic,  in  the  urine,  149      ' 
Summary    of    the    author's    method, 

100 
Surgery,  American,  tribute  to,  462 
newest  gastro-intestinal,  981 
of  the  appendix,  980 
of    the    stomach    and    intestines, 

986 
the    only    effective    resource    in 
tuberculous   stricture   of  intes- 
tine, 706 
Surgical     intervention     in     displace- 
ments of  the  colon,  455 
intervention    necessary    in    cica- 
tricial    contraction     of     either 
gastric  orifice,  557 
intervention    necessary    for    per- 
foration of  ulcer,  557 
method,   conservative,   in   appen- 
dicitis, 743 
method,   radical,   in   appendicitis, 

743 
treatment  of  obstructions  of  the 
gastric   orifices,  987 
Swedish    movements,    massage    and, 

268 
Sweets  often  disagree  after  a  dinner, 

why,  228 
Sympathetic  gastritis,  479 
Syphilis  of  stomach.  578 

Ehrlich's    "606"    for,    584 
Syphilitic  chronic  gastritis,  579 

disease  in  stomach  and  intestines, 

treatment  of,  584 
gastric  ulcer,  580 
Systematic  questioning,  67 
Symposium  on  appendicitis,  754 
Symptomatology  of  nervous  dyspep- 
sia, 872 


I032 


INDEX 


Table    showing    percentages    of    the 
various  symptoms  in  different 
forms  of  ileus,  697 
Talquist's  hemoglobin  scale,  177 
Tapeworms,  937 

etc.,  treatment  of,  946 
Tea  and  coffee,  231 
Technique      of      administering      oil 
enemas,  302 
of   applying   electricity   intragas- 

trically,  329 
of  blood  examination,  176 
of  examination  in  rectal  diseases, 

895 
of  rectal  alimentation.  248 
of  strapping  the  abdomen,  424 
Teeth  and  gums,  importance  of  care 
of,  191 
importance  of  inspecting,  75 
Temper,  irritability  of,  184 
Tenderness  on  palpation  in  enteritis, 
719 
on  pressure  a  symptom  of  gastric 

ulcer,  538 
on  pressure  over  epigastrium,  187 
Tenesmus,  187 
Tenia   saginata,  938 

solium,  938 
Test,  for  indican,  151 
dermoid,  134 
dinner,  118 
for  blood,  iron,  599 
for  lactic  acid,  127 
for  total  acidity,  155 
for  total  amount  of  solids,  152 
for  urinary  acidities,  Freund  and 

Topfer's.  156 
iodoform,  for  acetone,  159 
meal,   single  one  not  conclusive, 

119 
meals,  concerning,   117 
quantitative,  for  fatty  acids,  140 
quantitative,  for  lactic  acid,  140 
therapeutic,  between  cancer  and 

ulcer  of  the  stomach,  634 
quick,  for  indican.  150 
salol,  of  gastric  motility.  104 


Testing  for  gastric  acidity,  external 
method,  132 
vomitus  in  gastric  ulcer,  539 
Tests    for    albumin,    propeptone   and 
peptones,    131 
for   pepsin    and   the   rennet    fer- 
ment,  130 
for  the  other  organic  acids,  128 
for  the  salivary  digestion,  129 
for  uric  acid,  153 
of  capacity  of  the  stomach,  103 
of  gastric  contents  and  feces  in 

tubercular  cases,  958 
of  gastric  motility,  383 
of  stomach  contents,   126 
Tetany  from  cancer  of  the  stomach, 
607 
gastric,  treatment  of,  413 
Therapeutic  methods,  255 

test    of   carcinomatous    ulcer    of 
the  stomach,  634 
Therapeutics  of  secondary  cardiac  af- 
fections,   968 
overdosing  and  overdoing  In,  257 
Therapy,  manual,  307 
Thickening  of  the  pylorus,  619 
Throat,  etc.,  infection  from,  825 
Throats,  training  irritable,  112 
Tongue  coated  or  furred,  187 
Tonics,  bitter,  and  HCl,  remedies  for 
anorexia,  849 
nerve,  354 
Total  acidity,  test  for,  155 

amount  of  solids,  test  for,  152 
Toxic  gastritis,  479 

gastritis,    diagnosis   of.   480 
gastritis,  pathology  of,  480 
gastritis,  symptoms  of,  480 
gastritis,  treatment  of,  481 
Tract,  digestive,  anatomy  of,  29 
Training  irritable  throats,  112 
Treatment,     after,     of     membranous 
catarrh  of  the  intestines,  819 
prognosis  and,  of  tumors  of  the 

intestines.  665 
classification  of  diseases  with  re- 
gard to  dietetic,  216 


INDEX 


Treatment,  comparison  of  results 
from  surgical  and  mechanical, 
468 

curative,  of  gastric  ulcer,  551 

dietetic,  of  carcinoma  of  the 
stomach,  645 

dietetic,  of  membranous  catarrh 
of  the  intestines,  815 

mechanical  forms  of,  in  chronic 
gastritis,  499 

medicinal  and  palliative,  of  car- 
cinoma and  other  tumors  of 
the  stomach,  644 

medicinal,  in  acid  gastritis  and 
HCl  excess,  522 

medicinal,      in      gastric      ulcer, 

554 
medicinal,  of  gastritis,  502 
of  achylia  gastrica,  834 
of  acid  gastritis  and  HCl  excess, 

S14 
of    acute    catarrhal    appendicitis, 

755 

of  acute  dilatation  of  the  stom- 
ach, 387-388 

of  acute  enteritis,  711 

of  acute  gastritis,  474 

of    acute    intestinal    obstruction, 

699 

of  amoebic  dysentery,  805 

of  ankylostoma  duod.,  945 

of  anorexia,  849 

of  atonic  dilatation  of  stomach, 
410 

of  bacillary  dysentery,  800 

of  benign  tumors  in  the  stom- 
ach, 619 

of  benign  tumors  of  the  intes- 
tines, 667 

of  benign  tumors  of  the  rectum, 
916 

of  bulimia,  846 

of  cancer  of  stomach,  636,  651 

of  carcinoma  of  the  stomach 
with  X-rays,  etc.,  636 

of  cardiospasm,  854 

of  catarrhal  dysentery,  796 


1033 

Treatment   of   chronic   catarrhal   ap- 
pendicitis, 759 
of  chronic  dysentery.  806 
of      chronic      gastric      catarrh, 
dietetic  and  hygienic,  496 

of  chronic  intestinal  catarrh,  722 

of  colica  mucosa  in  true  enter- 
itis, 820 

of   coloptosis,   454 

of  complications  and  sequels  of 
gastric  ulcer,  556 

of    complications    of    rectal    ab- 
scess, 913 

of    congenital     stenosis    of    the 
pylorus,  439 

of  constipation,  775 

of  constipation  in  nervous  dys- 
pepsia, 878 

of  diarrhea,  785 

of  dilatation  of  stomach,  405 

of  diseases  of  stomach,  place  of 
HCl  in,  332 

of  displacements  of  intestines, 
459 

of  duodenal  ulcer,  564 

of  erosions  of  stomach,  558 

of  fecal  impaction,  903 

of  fissure  of  anus,  910 

of  fistula  in  ano,  915 

of  flatulency,  826 

of  foreign  bodies  in  stomach, 
619 

of  gastric  atony,  384 

of  gastric  hypersesthesia,  842 

of  gastric  phlegmon,  483 

of  gastric  tetany,  413 

of  gastritis,  chronic,  496 

of  gastro-intestinal  cancers,  early 
diagnosis  indispensable  for, 
639 

of  gastroptosis,  434 

of  gastrospasm,  851 

of  hyperchlorhydria,  525,  530 

of  hemorrhage  from  the  stomach 
and  intestines,  600 

of  hemorrhoids,  906-907 

of  intestinal  neuroses,  888 


I034 


INDEX 


Treatment    of    intestinal    ulceration, 

591 
of  intussusception,  682 
of  ischiorectal  abscess,  913 
of  membranous  catarrh  of  the  in- 
testines, 814 
of  movable  kidney,  423 
of  nervous  vomiting,  861 
of     obstruction     from     external 
tumors,   displaced  organs,  etc., 
691 
of  paralysis  of  the  intestines,  890 
of  peristaltic  restlessness,  858 
of  peristaltic   unrest   of   the   in- 
testines, 890 
of  pernicious  vomiting  of  preg- 
nancy, 863 
of  pruritus  ani,  910 
of  pyloric  insufificiency,  870 
of  rectal  prolapse,  918 
of  regurgitation  and  rumination, 

867 
of   sarcoma   and   benign   tumors, 

650 
of  spasm  of  the  pylorus,  857 
of  strangulation  ileus,  688 
of  stricture  of  the  rectum,  920 
of  syphilitic  disease  in  the  stom- 
ach and  intestines.  584 
of     tapeworms,     round     worms, 

etc.,  946 
of  the  colic  form  of  intussuscep- 
tion, 683 
of   the    severer    forms    of    acute 

appendicitis,  757 
of  toxic  gastritis,  481 
of  trichinosis,  950 
of  trichocephalus  dispar,  952 
of  tubercular  ulcers  of  the  stom- 
ach and  intestines,  572 
of  tumors  of  the  rectum,  927 
of  ulceration  of  the  rectum,  92J 
of  volvulus,  684 
Treatments    through    the    spine    and 

spinal  nerves,  305,  783 
Trichina  spiralis,  949 
Trichinosis,  949 


Trichocephalus  dispar,  illustration  of, 

951 
Tube,  how  to  introduce  most  easily, 
108 
mode  of  introducing,  iii 
stomach,    best    kind    for    lavage, 

315 

stomach,    contra-indications    for, 
114 

stomach,       sometimes       imprac- 
ticable, 91 
Tubercular  ulcerations  of  the  gastro- 
intestinal   tract,    climatic    and 
hygienic  measures  in,  575 

ulcers  and  growths  as  causes  of 
chronic  obstruction,  705 

ulcers     in     stomach     and    intes- 
tines, 573 

ulcers   of  intestines,    special   site 
of,  568 

ulcers,   symptomatology  of,   569 
Tuberculin    treatment    of    tubercular 
ulcers    in    stomach    and    intes- 
tines, 573 

Pottenger's   method  of   adminis- 
tering, 573 
Tuberculosis  of  intestines  generally  a 
secondary  process,  568 

of       intestines,       palpation       in, 
568 

of  intestines,  secondary,  a  hope- 
less condition,  572 

of  intestines,  surgery  of,  993 

relations  of,  to  the  gastro-intes- 
tinal   functions,  955 
Tuberculous    ulcer    of    the    stomach, 
frequency  of,  569 

stricture  of  ileum,  702,  704 
Tuholske's  description  of  strangula- 
tion ileus,  686 
Tumor  sometimes  palpable  in  gastric 

ulcer,  540 
Tumors,  abdominal,  differential  diag- 
nosis  of   gastric   cancer    from, 
628 

benign,    of    intestines,    treatment 
of,  667 


INDEX 


1035 


Tumors,  benign,  or  foreign  bodies  in 
stomach,  treatment  of,  619 
external,    displaced    organs,   etc., 
as      causes      of      obstruction, 
689 
external,    symptoms    of   obstruc- 
tion by,  690 
intestinal,  surgery  of,  992 
of   intestines,    complications   and 

course   of,  660 
of  intestines,  diagnosis  of,  661 
of  intestines,  diagnostic  points  in, 

664 
of  intestines,  how  located,  662 
of  intestines,  pathology  of,  653 
of      intestines,      prognosis      and 

treatment  of,  665,  995 
of  intestines,  symptomatology  of, 

654 
of  rectum,  benign,  923 
of  rectum,  malignant,  925 
of  s!:omach,  benign,  618 
Turck's     apparatus     for     pneumatic 
gymnastics,  illustration  of,  299 
gyromele,  87 
gyromele  as  an  aid  in  diagnosing 

gastrectasis,  402 
gyromele  as  an  electrode,  324 
lavage   of  colon   for   chronic   in- 
testinal catarrh,  727 
method  of  doing  massage  of  the 

colon,  301 
stomach  sprinkling  tube,  318 
Tuttle's  formula  for  injection  treat- 
ment of  hemorrhoids,  907 
Tuttle's  pneumatic  proctoscope,  899 
Tympanites,  880 

meteorism,  or  flatulency,  883 
Tympany,  abdominal,  187 
Typical    symptoms   of  cancer    rarely 
all  present,  610 


Ulcer,  carcinomatous,  633 

carcinomatous,  of  stomach,  625 
carcinomatous,        of        stomach, 
therapeutic  test  for,  634 


Ulcer,    diagnosis    from    acid    gastric 
catarrh,  511 
differentiated  from  cancer  of  the 

cardia,  631 
duodenal,  constipation  in,  561 
duodenal,  jaundice  in,  561 
duodenal,  symptoms  of,  560 
gastric,  complications  of,  540 
gastric,     curative    treatment    of, 
,    551 
gastric  diagnosis  of,  from  Reich- 

mann's  disease,  529 
gastric,  diet  in,  551 
gastric,  hemorrhage  in,  540 
gastric,  massage  in,  554 
gastric,      nutritive      enemas     in, 

552 
gastric,  pathology  of,  535 
gastric,  perforation  of,  9S6 
gastric,     prophylactic     treatment 

of,  549 
gastric,  sequels  of,  541 
gastric,  symptomatology  of,  536 
gastric,  syphilitic,  580 
gastric,    treatment    of    complica- 
tions and  sequels  of,  556 
incidence  of,  as  to  sex  and  age, 

534 
latent,    a    cause    of     failure    in 
treatment   of   supposed   hypcr- 
chlorhydria   by   electricity,  330 
to  be  suspected  in  cases  of  stub- 
born  hyperchlorhydria   or  hy- 
persecretion, 539 
medicinal  treatment  in  gastric,  554 
of  duodenum,  diagnosis  of,  from 

ulcer  of  stomach,  545 
of  pyloric  end  of  stomach,  535 
of    stomach,    diagnosis    of    from 

ulcer  of  the  duodenum,  545 
of  stomach,  aetiology  of,  533 
of  stomach,  spontaneous  healing 

of,  549 
of  stomach,  therapeutic  test,  543 
perforation  in  gastric,  540 
round,    of    duodenum,    diagnosis 

of,  562 


1036 


INDEX 


Ulcer,  round,  of  duodenum,  aetiology 
and  pathology  of,  559 
round,    of    duodenum,   prognosis 

of,  564 
round,    of    duodenum,    treatment 
of,  566,  992 
Ulcerating  carcinoma  of  the  rectum, 

659 
Ulceration,    intestinal,    diagnosis    of, 

590 

intestinal,  symptoms  of,  588 

intestinal,  treatment  of,  591 

intestinal,  various  forms  of,  585 

of  the  rectum,  922 
Ulcers,  amyloid,  588 

embolic  and  thrombotic,  587 

gouty,  588 

healed,  strictures  from,  obstruct- 
ing the  bowels,  701 

of  the  intestines,  catarrhal,  587 

peptic,  981 

scars  of,  as  causes  of  intestinal 
obstruction,  674 

stercoral,  587 

strictures     from     scars     of,     as 
causes    of    bowel    obstruction, 

673 
toxic,  587 
tubercular,  as  causes  of  chronic 

obstruction,  705 
tubercular,    diagnosis   of,    in   the 

stomach  and  intestines,  570 
tubercular,  of  the  intestines,  567 
tubercular,   of   the   stomach   and 

intestines,  prognosis  of,  572 
tubercular,    of   the    stomach   and 

intestines,  treatment  of,  572 
tubercular,    of  the    stomach,   pa- 
thology of,  568 
Umbilical  hernia,  684 
Uncinaria  americana,  942 
Undigested  milk  curds  in  feces,  167 
Upper  part  of  abdomen,  position  of 

organs  in,  33 
Uranalysis    indispensable    in    gastro- 
intestinal affections,  143 
Uratic  diathesis,  diet  in,  225 


Urea,  154 

largely  produced  in  the  liver,  59 
Uric  acid  excess,   150 

acid,    Folin-Hopkins    method    of 
determining  the  amount  of,  154 
acid,  tests  for,  153 
Urinary       acidities',       Freund       and 
Topfer's    test   for,    156 
acidity  and  HCl  secretion,  rela- 
tion between,  144 
Urine,     partial     examination     better 
than  none,  148 
the,  in  enteritis,  710 


V-shaped  transverse  colon,  illustra- 
tion of,  450 

Valuable  effects  of  hydrochloric  acid, 
335 

Van  Valzah  and  Nisbet,  statistics  of, 
as  to  the  gastric  secretions  in 
incipient  phthisis,  957 

Vaso-constrictors  and  vaso-dilators, 
their  origin  in  the  spine,  49 

Vaso-motor    nerves    and    the    spine, 
48 
nerves,  points  of  emergence  of, 

51 

Varieties  of  cancer  of  the  stomach, 
603 

Vegetable  cells  in  feces,  167 
diet,   203 

Veins  and  lymphatics,  39 

Vessels,  blood,  of  the  stomach,  38 

Vertical  stomach,  403 

Vertigo,  187 

Vichy   and   Kissingen   waters,    Sara- 
toga, 350 
water,   French,  350 

Villi,  intestinal,  60 

Viscera,  instruments  for  determin- 
ing  the    size   and   position    of, 

8S 
radiographs  of,  102 
Volvulus  of  intestine,  683 
of  stomach,  435 
surgical  treatment  of,  996 


INDEX 


1037 


Volvulus,  S3'mptoms  of,  683 
treatment   of,   684,   996 
Vomit  and  stools,  blood  in  both,  598 
and  stools,  significance  of  blood 
in,  595 
Vomiting,     a     symptom     of     gastric 
ulcer,  538 
an  important  symptom  of  pyloric 

cancer,  611 
in  obturation  ileus,  696 
in  gastric  ulcer,  538 
nausea  and,  not  common  results 

of  passing  stomach  tube,  112 
nervous  and  reflex,  859 
of  pregnancy,  pernicious,  863 
or  nausea,  184 
Von   Noorden's   book   about    Effects 
of  Saline  Waters  on   IMetabo- 
lism,  352,  532 


Wet  compress  over  stomach  for  acute 
gastritis,  475 

Whittaker's  method  of  administering 
tuberculin,  574 

Wiesbaden,  Homburg,  and  Kissingen 
waters  in  chronic  gastritis,  500 

Withholding  of  food  advised  in  acute 
gastritis,  475 

Worms  as  a  cause  of  excessive  appe- 
tite, 846 
obturation  by,  as  a  cause  of  in- 
testinal  obstruction,  673 

Wrinkle,   practical,   for   carrying   out 
lavage,  318 
practical,    for    lavage    in    sthenic 
gastritis,  519 

Wylie's  views  as  to   frequent   cause 
of  pelvic  displacements,  462 


Washing  out  the   stomach,   312,    500 
Wassermann    serum    test    for   syphi- 
lis,   578 
Water    drinking   in    dyspeptic    condi- 
tions, 233 
free    drinking    of    warm,    as    a 
remedy  for  acute  gastritis,  476 
milk,  etc.,  dietetically  considered, 
232 
Waters,   ferruginous  mineral,   357 
medicinal,  in  chronic  enteritis,  726 
mineral,  alkaline,  349 
saline  or  chloride,  351 
spring,    in    hj'perchlorhydria,    531 
Weber's     modified     test     for     occult 

blood,   599 
Weight  in  stomach,   185 


X-rays,  etc ,  treatment  of  carcinoma 
of  the  stomach  with,  636-639 

radium,  etc.,  in  cancer  of  the 
stomach,  636,  641,  642,  643 

radium,  etc.,  in  tumors  of  the  in- 
testines, 665 


Yeast  fungi  and  columnar  epithelium 
from   a   case   of  acid   gastritis, 

509 

illustration  of,  141 


Z'inc-mercury  cataphoresis   in   cancer 
of  the  intestines,  665 
cataphoresis  in  malignant  tumors 
of  the  rectum,  928 


THE    END 


!i  i 


